Failure to Follow Enhanced Barrier Precautions and Equipment Disinfection Protocols
Penalty
Summary
Staff failed to follow infection prevention and control protocols related to Enhanced Barrier Precautions (EBP) and equipment disinfection for multiple residents with indwelling medical devices. For a resident with a Foley catheter due to neurogenic bladder, staff were observed performing catheter care and draining the catheter without donning a gown, despite facility policy and posted signage requiring both gown and gloves for high-contact care activities. The staff member acknowledged awareness of the EBP requirements but did not comply during the observed care. Another resident with a feeding tube and frequent incontinence was observed receiving tube feeding and medication administration from an LPN who only wore gloves, omitting the required gown and mask during high-contact activities involving the G-tube. The LPN later admitted this was an error and that full PPE should have been used. During incontinence care for the same resident, CNAs wore gloves and gowns, but one CNA's gown was not properly secured and repeatedly fell from his shoulders, compromising the effectiveness of the barrier precautions. Additionally, the same CNA was observed touching multiple surfaces in the room with contaminated gloves before changing them, increasing the risk of cross-contamination. In a separate incident, two CNAs used a mechanical lift to transfer a resident who required total assistance. After the transfer, the lift was not disinfected before being moved to a common storage area, contrary to facility protocol and staff interviews indicating that equipment should be wiped down after each use. The facility's policy and CDC guidance both require cleaning and disinfection of shared equipment and the use of gown and gloves for high-contact care activities involving residents with indwelling devices or wounds.