Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for multiple residents with conditions requiring such precautions. For a resident with renal insufficiency, a multidrug-resistant organism (MDR), and wounds, staff did not change gloves or perform hand hygiene between tasks and failed to wear gowns as required by EBP during repositioning and wound care. Similarly, another resident with an indwelling catheter and positive MRSA status was transferred and repositioned by staff who did not change gloves or perform hand hygiene, and did not wear gowns as required. Staff interviews confirmed awareness of the need for gowns and proper hand hygiene, but these practices were not followed during observed care. In another case, a resident with a chronic vascular ulcer and EBP orders for wounds received wound care from an LPN who inconsistently performed hand hygiene between glove changes and used paper towels instead of a chuck pad as a barrier for dressing supplies. The LPN also used sanitized scissors to cut through dressing packaging, which was not in line with facility expectations. The resident reported that only certain staff wore gowns during treatments, and interviews with staff revealed confusion about EBP signage and inconsistent use of PPE prior to the current week. A further deficiency was observed with a resident who had a stage 4 pressure ulcer and was on EBP for wounds. During wound and peri care, an RN did not consistently perform hand hygiene between glove changes, used improper techniques for cleansing and ointment application, and required reminders from another staff member to use a gown and perform hand hygiene. Facility policy and staff interviews confirmed that hand hygiene should be performed after glove removal and between tasks, and that PPE should be used as indicated by EBP orders, but these protocols were not consistently followed during the observed care.