Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures in multiple instances, as observed by surveyors. Laundry staff were seen handling soiled resident clothing while wearing only gloves, without the use of gowns or aprons as barriers, contrary to the facility's policy that requires standard precautions and the use of barriers to prevent contamination of uniforms. The staff member stated that gowns or aprons were only used for heavily soiled laundry, which does not align with the written policy. For one resident with chronic vascular ulcers and impaired cognition, staff did not follow Enhanced Barrier Precautions (EBP) during high-contact care activities such as toileting, transferring, and wound care. Despite clear care plan directives and physician orders to use gowns and gloves for all high-contact care and wound dressing changes, staff were repeatedly observed performing these tasks without the required personal protective equipment. Staff also demonstrated a lack of awareness regarding the EBP signage and its application to the resident in question. Another resident with a surgical wound and skin breakdown under a leg immobilizer did not have consistent EBP implemented. Staff were unaware of the skin breakdown, and there was a lack of clear care plan direction for monitoring and dressing changes. Observations revealed that staff did not always use gowns and gloves during wound care, and EBP signage was missing from the resident's room. Additionally, there was confusion among staff regarding the need for EBP for non-chronic wounds, and inconsistent documentation and assessment of the resident's skin condition.