Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a consistent infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, wounds, and surgical artificial openings. Observations revealed that staff did not use required personal protective equipment (PPE) such as gowns during high-contact care, and there was no signage or accessible PPE in or around the rooms of affected residents. Staff members, including a CNA, were unaware of EBP requirements and did not follow aseptic technique when providing catheter care, such as cleaning the outlet tube with an alcohol wipe after emptying the drainage bag. Administrative nurses confirmed they were not aware of the updated CMS directive for EBP and acknowledged that infection control logs were not completed or reviewed in a timely manner to track and trend infections as they occurred. Additionally, the facility did not have a documented water management program to mitigate the risk of Legionella and other waterborne pathogens, nor did it have a policy addressing the prevention of Legionella. The infection control program documentation was incomplete, lacking evidence of surveillance systems to identify and track infections in real time. The facility's failure to implement these infection control measures and maintain proper documentation had the potential to contribute to the spread of infections among residents, particularly those with indwelling devices or wounds.