Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precaution (EBP) guidelines and infection control protocols for multiple residents. For one resident with sacral wounds and orders for EBP and MDRO precautions, staff did not include EBP interventions in the care plan. During observed care activities, occupational therapy staff wore gloves but did not don gowns as required for high-contact care, such as assisting with activities of daily living and wound care. Staff also failed to perform hand hygiene before entering and after leaving the resident's room, and there was confusion among staff regarding which residents required EBP, with one staff member incorrectly associating EBP only with residents who have a PEG tube. In another instance, a resident with diabetes underwent blood glucose monitoring by an LPN who did not perform hand hygiene before or after the procedure, did not clean the resident's finger before pricking, and failed to properly disinfect and store the glucometer according to manufacturer instructions. The LPN used disinfectant wipes but did not allow the required drying time before returning the glucometer to the medication cart and did not store it in a bag. The same gloves were used to handle multiple items, including the medication cart and disinfectant container, without changing gloves or performing hand hygiene between tasks. Additionally, during glucose monitoring for another resident, an RN brought unused lancets and a glucose strip container into a resident's room with EBP signage and then returned these items to the medication cart, contrary to infection control protocols. The DON confirmed that unused lancets and glucose strip containers should not be brought back into the medication cart after being in a resident's room. These observations indicate multiple failures to follow established infection prevention and control procedures, including proper use of PPE, hand hygiene, and equipment disinfection and storage.