Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving three residents with indwelling medical devices and wounds. For one resident with a suprapubic catheter, the catheter bag was observed lying on the floor while the resident was in bed, which was acknowledged by facility leadership as inappropriate placement. Another resident with a gastrostomy tube and wounds was observed during care where the registered nurse inconsistently performed hand hygiene, failed to use a gown as required by Enhanced Barrier Precautions (EBP), and did not maintain a clean environment when handling supplies and performing dressing changes. The nurse also failed to use a barrier for clean supplies and did not consistently change gloves or perform hand hygiene between clean and dirty tasks. A third resident, who was totally dependent on staff for hygiene and had an indwelling urinary catheter and wounds, received personal incontinence care from two certified nurse aides. During this care, the staff did not wear gowns as required by EBP, and the resident's catheter bag was placed on the bed during the procedure. Facility policy required the use of gown and gloves for high-contact care activities involving indwelling devices and wounds, but these protocols were not followed during the observed care events. Interviews with facility leadership confirmed that the observed practices did not meet the facility's expectations or policy requirements for infection control, hand hygiene, and EBP. The facility's own policies, as well as posted signage, specified the need for gown and glove use during high-contact care for residents with indwelling devices or wounds, and for proper hand hygiene before and after glove use and care activities. These deficiencies were identified through direct observation, record review, and staff interviews.