Failure to Follow Contact and Enhanced Barrier Precautions for Infection Control
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents requiring contact precautions and enhanced barrier precautions (EBP). For one resident with an active C. difficile infection, staff did not follow posted contact precaution protocols. Specifically, a housekeeper was observed mopping the resident's room without wearing a gown, despite signage and facility policy requiring both gown and gloves for entry and cleaning in such cases. The housekeeper confirmed not wearing the required gown, and the regional nurse consultant verified that this was not in accordance with the resident's isolation status and facility policy. For two other residents, both of whom required EBP due to the presence of indwelling medical devices or multidrug-resistant organisms (MDROs), staff did not wear gowns during high-contact care activities. In one instance, two nursing assistants provided post-shower care, perineal care, and dressing changes to a resident with a urinary catheter and a wound dressing, without wearing gowns. Both staff members stated they were unaware that gowns were required or that the resident was on EBP. In another case, two nursing assistants transferred a resident with an MDRO and a vascular access port for dialysis, and one continued to provide perineal care and a brief change, all without wearing a gown. The staff involved and a registered nurse confirmed they were not aware of the EBP requirement for this resident. Facility policy required the use of gowns and gloves for contact precautions and EBP during high-contact activities for residents with certain infections or indwelling devices. Observations and staff interviews confirmed that these protocols were not followed for the residents in question, despite clear signage and policy directives. The failure to adhere to these precautions was acknowledged by both the staff involved and the regional nurse consultant.