Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and droplet/contact precautions. For one resident with obstructive uropathy and an indwelling catheter, staff did not follow EBP guidelines as outlined in the care plan and facility policy. During an observed catheter care procedure, the certified nursing assistant (CNA) wore gloves but did not don a gown as required. Additionally, after urine was spilled on the floor, the CNA cleaned the area with a paper towel instead of using an appropriate disinfectant, contrary to the infection preventionist's expectations and facility policy. Staff interviews revealed inconsistent understanding and application of EBP protocols. One CNA believed EBP was only necessary for residents with certain infections like influenza, COVID, or C. difficile, while another stated she would use a gown and gloves for catheter care if an EBP sign was posted. The infection preventionist clarified that a gown and gloves should always be used for catheter care and that contaminated surfaces must be disinfected with approved wipes, not just wiped with a paper towel. In a separate incident, another resident with respiratory symptoms and a diagnosis of Parainfluenza Type 2 was not placed in transmission-based precautions (TBP) until after returning from the emergency department, despite having symptoms for several days. Staff interviews indicated a lack of clarity regarding when to initiate isolation and which type of precautions to use. The care plan was not updated to reflect the resident's symptoms or need for TBP until after the diagnosis was confirmed, and the resident continued to participate in communal dining while symptomatic.