Failure to Implement Effective Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple staff not performing proper hand hygiene and not following Enhanced Barrier Precautions (EBP) during wound care for three residents. Observations revealed that staff, including LPNs and the MDS Coordinator, did not perform hand hygiene before or after glove changes, after contact with potentially contaminated surfaces, or between different wound care tasks. Supplies such as wound cleanser bottles and dressings were placed on potentially contaminated surfaces without barriers, dropped on the floor and reused, and shared between residents, including those with MRSA, without proper disinfection or dedicated use. For one resident with a history of stroke, diabetes, and MRSA in a buttock wound, staff failed to perform hand hygiene at multiple points during wound care, reused supplies that had fallen on the floor, and returned unused supplies from the resident's room to the general treatment cart. Similar lapses were observed with two other residents, one with diffuse large B-cell lymphoma and surgical wounds, and another with MRSA infection and heart failure. In all cases, EBP signage was missing, PPE carts were not consistently available, and staff did not consistently use gowns and gloves as required for high-contact care activities. Interviews with staff and leadership revealed a lack of training and awareness regarding EBP, with several staff members unable to define EBP or describe when and how to implement it. Staff also reported inconsistent practices regarding the use and disposal of wound care supplies, hand hygiene, and PPE. Facility policies required hand hygiene and the use of PPE, but these were not followed in practice, and there was no evidence of staff education or competency assessment on EBP.