Failure to Follow Enhanced Barrier Precautions and Proper Disinfection Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not following enhanced barrier precautions (EBP) and improper disinfection of shared medical equipment. For two residents with significant medical conditions, including muscle weakness, spinal fusion, hemiplegia, and the presence of invasive devices such as a PICC line and urinary catheter, staff did not consistently wear the required personal protective equipment (PPE) during high-contact care activities. Observations showed that certified nursing assistants provided personal hygiene and handled urinary catheter bags for these residents while wearing gloves only, omitting gowns, despite clear signage and facility policy requiring both gloves and gowns for EBP cases. Staff interviews confirmed a lack of awareness or adherence to EBP protocols, even though the facility had provided training and had clear expectations for PPE use during such care activities. Additionally, a licensed vocational nurse was observed cleaning a glucometer used for multiple residents without properly disinfecting all surfaces according to manufacturer instructions and facility policy. The nurse acknowledged not using a new wipe for each surface and not ensuring the device remained wet for the required contact time. This improper disinfection practice was confirmed during interviews and was contrary to both the manufacturer's guidelines and the facility's written procedures for glucometer cleaning and disinfection. These lapses in infection control practices, including failure to use appropriate PPE during high-contact care and inadequate disinfection of shared medical equipment, created conditions that could facilitate the transmission of infectious agents among residents and staff. The facility's own policies and staff statements indicated an understanding of the required procedures, but observations and interviews demonstrated inconsistent implementation at the point of care.