Staff Lacked Competency in Infection Control Precautions
Penalty
Summary
The facility failed to ensure staff competency in Infection Control, specifically regarding Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP), across three units. Surveyors observed that PPE was present on resident doors without appropriate signage indicating when or what PPE should be used. Multiple staff members, including RNs, CNAs, and Environmental Services workers, were unable to correctly identify the type of precautions in place or the correct use of PPE. Some staff relied on verbal reports or care plans for information, but there was confusion and inconsistency in understanding the difference between TBP and EBP. In several instances, staff either did not know the reason for PPE placement or misunderstood the requirements for donning PPE, with some believing PPE was only necessary for certain activities or misinterpreting color-coded indicators. Record review revealed that the facility's Enhanced Barrier Precautions Performance Improvement Plan had not been reviewed or revised since its last update, and there was no evidence of ongoing staff competency assessments or knowledge checks since the plan's initiation. The Infection Preventionist acknowledged ongoing issues with staff understanding of TBP and EBP, despite the implementation of the improvement plan. These findings demonstrate a lack of effective implementation and staff education regarding infection control protocols, as evidenced by direct observations and staff interviews.