Deficient Infection Surveillance and PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement an effective infection surveillance program and did not ensure staff used appropriate personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The Infection Preventionist (IP) reported that her surveillance activities were limited to tracking antibiotic use and facility-acquired infections, but she was often unaware of residents exhibiting signs or symptoms of infection. There was no established system for nursing staff to report potential infections or lab tests, and the IP relied on antibiotic orders in the electronic medical record (EMR) to identify cases. The IP also did not consistently document the criteria used to determine infections or the final determination in her surveillance records. She acknowledged that the surveillance program was inadequate, citing poor communication with newer staff and a lack of a structured reporting system as barriers. A review of the facility's infection surveillance policy indicated that surveillance should include multiple sources of information, such as laboratory records, skin care sheets, infection control rounds, verbal staff reports, and more. However, the IP admitted to not utilizing all available data sources and expressed difficulty using the EMR-generated spreadsheet, which further hindered her ability to maintain comprehensive surveillance. The policy also required detailed documentation for each infection, but this was not consistently performed. Additionally, direct observation revealed that a Certified Nursing Assistant (CNA) failed to follow EBP protocols during urinary catheter care for a resident. The CNA did not don a gown, failed to sanitize hands before donning gloves or when changing gloves, and placed personal care items inappropriately with clean linen. The CNA was unaware that the resident was on EBP, despite signage indicating this. Both the IP and the Director of Nursing (DON) confirmed that the observed practices did not comply with the facility's EBP policy, which mandates gown and glove use during high-contact care activities such as catheter care.