Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and during medication administration. For one resident with a pressure wound, an LPN performed wound care without wearing a gown, did not follow correct wound cleaning technique by reusing the same gauze on the wound bed, and used a towel from the bedside table to pat the wound dry. There was no EBP sign posted outside the resident's room, and the care plan did not address the use of EBP, despite a physician's order requiring these precautions. The LPN was unaware of the required PPE for EBP, and the Director of Nursing confirmed the absence of the sign and staff awareness. In another instance, an RN was observed preparing medications and, after dropping a tablet onto the medication cart, picked it up with her fingers and placed it into the medication cup, contrary to infection control procedures and facility policy, which prohibit touching medications with bare hands. The RN acknowledged this was not the correct procedure and that the medication should have been replaced. Additionally, a resident with wounds on the vagina and buttocks had wound care supplies stored on top of the dresser in her room. The resident reported that staff only wore gloves, not gowns, during wound care. There was no EBP sign on the door or PPE available outside the room, despite a physician's order for EBP. The care plan did not include EBP at the time wound care was initiated, and the order for EBP was delayed. Interviews with staff confirmed that EBP should have been implemented earlier and that proper signage and PPE availability were lacking.