Failure to Implement Enhanced Barrier and Contact Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact Precautions as required for two residents. For one resident with a stage 4 pressure ulcer on the right heel and severe cognitive impairment, there was no physician's order for EBP, no EBP care plan in place, and no EBP signage or isolation cart with personal protective equipment (PPE) near the resident's room. During wound care, the registered nurse performed the procedure without donning a gown, and only gloves were used. The infection preventionist confirmed that there was no EBP care plan for this resident, despite the presence of a chronic wound that met the criteria for EBP according to facility policy. For another resident on contact precautions due to a recent diagnosis, the required infection control measures were not fully implemented. Although a sign indicating contact precautions was posted on the resident's door, a registered nurse was observed starting an intravenous medication while wearing gloves but not a gown, contrary to CDC guidelines and facility policy, which require both gown and gloves for all interactions that may involve contact with the resident or their environment. These deficiencies were confirmed through observations, interviews, and record reviews. The administrator and director of nursing acknowledged the findings during the survey. The failures were directly related to lapses in following established infection prevention and control policies, including the absence of required care plans, signage, and proper use of PPE during resident care activities.