Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Standards
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) and proper infection control measures during direct care of residents with increased risk for infection. Specifically, a licensed nurse administered intravenous antibiotics to a resident with a peripherally inserted central catheter (PICC) without donning a gown as required by EBP protocols, and later exited the resident's room wearing gloves, using the door handle, and entering the hallway without removing gloves or performing hand hygiene. Certified nurse aides (CNAs) providing peri-care to residents did not perform hand hygiene between glove changes, and in one instance, only changed one glove instead of both before continuing care. These actions were inconsistent with the facility's policy, which requires hand hygiene before donning new gloves and after glove removal, as well as the use of all required personal protective equipment (PPE) for residents under EBP. Additionally, respiratory equipment was not stored in a sanitary manner. Oxygen tubing for a resident was observed stored in a plastic bag with large holes, and the bag was placed on the floor, contrary to infection control expectations. Staff interviews confirmed awareness of proper storage requirements, but these were not followed in practice. The facility did not provide a policy specific to the care of respiratory supplies, despite having a general policy on standard and transmission-based precautions.