Infection Control and Enhanced Barrier Precautions Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in housekeeping and direct care practices. Housekeeping staff did not follow proper infection control guidelines when cleaning resident bathrooms, including not cleaning from cleaner to dirtier areas and using the same rag for both the toilet and grab bars. Additionally, a housekeeper was observed applying alcohol-based hand sanitizer and immediately donning gloves without allowing the sanitizer to dry, which is contrary to CDC guidelines and reduces the effectiveness of hand hygiene. The housekeeper also placed a dirty toilet brush container on a cleaned sink surface, further contributing to cross-contamination risks. Staff failed to adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds and indwelling devices. Multiple instances were observed where staff, including CNAs and a restorative nurse aide, provided high-contact care activities such as repositioning, range of motion exercises, and changing linens for residents on EBP without donning the required gowns and, in some cases, gloves. One LPN performed wound care for a resident on EBP wearing only gloves and not a gown, despite clear signage and facility policy requiring both gown and gloves for such activities. Interviews with staff revealed gaps in knowledge and understanding of EBP requirements, with some staff unaware that gowns were necessary for certain care activities. The residents involved had significant medical needs, including wounds, diabetic ulcers, pressure injuries, indwelling catheters, and colostomies, placing them at high risk for infection. Despite facility policies and posted signage outlining the need for PPE and proper cleaning procedures, staff did not consistently follow these protocols during the provision of care and environmental cleaning. These failures were corroborated by staff interviews, which confirmed lapses in both knowledge and practice regarding infection control and EBP implementation.