Failure to Follow Enhanced Barrier Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and regulatory standards. Specifically, a licensed nurse provided suprapubic catheter care to a resident using gloves but did not don a gown, as required under Enhanced Barrier Precautions (EBP) for high-contact care activities involving indwelling medical devices. Additionally, another licensed nurse assisted a certified nurse aide in transferring a resident using a Hoyer lift and subsequently placed the lift in a hallway cubby without disinfecting it between resident uses, contrary to facility policy and CDC recommendations. Interviews with administrative nursing staff confirmed that staff were expected to follow EBP protocols and clean equipment such as Hoyer lifts between each resident use. The facility's own policies, dated October 2024 and 2018, outlined the need for EBP during high-contact care and for cleaning and disinfecting resident-care equipment according to CDC and OSHA standards. These lapses in following established infection control procedures were observed during routine care activities and placed residents at risk for infection.