Failure to Implement Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving several residents with complex medical needs, including those with catheters, wounds, and enteral tubes who were on Enhanced Barrier Precautions (EBP). Direct observation revealed that a registered nurse (RN) did not perform hand hygiene before donning gloves, failed to clean the blood glucose monitor between residents, and did not prime insulin pens as required. The same blood glucose monitor was used on multiple residents without proper disinfection, and the cleaning process did not adhere to the manufacturer's instructions for contact time with disinfectant wipes. The RN also admitted to not being instructed on priming insulin pens and was unaware of the required wet time for disinfectant wipes. Further observations showed that staff did not consistently use personal protective equipment (PPE) as required under EBP protocols. During wound care and catheter care for a resident, the RN failed to don PPE as mandated by EBP, despite the resident having a pressure ulcer and an indwelling catheter. In another instance, a resident with a feeding tube and an EBP sign on the door received medication and tube feeding from the RN without the use of PPE. The RN entered and exited the room multiple times, performing care activities without donning the necessary gown and gloves, even though PPE was available in the room. Interviews with the RN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that staff were expected to follow EBP protocols, including the use of PPE during high-contact care activities for residents with wounds or indwelling devices. The DON and ADON acknowledged that the observed practices did not meet facility expectations or CDC guidelines. Facility policies reviewed by surveyors also required adherence to hand hygiene, proper cleaning of medical equipment, and the use of PPE as outlined by EBP and manufacturer instructions.