Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to established infection prevention and control standards for 9 of 10 sampled residents during care activities. Observations revealed that staff did not consistently follow Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care for residents with indwelling devices, wounds, or a history of multidrug-resistant organisms. In multiple instances, staff performed hand hygiene and donned gloves but neglected to wear gowns as required by EBP policy. For example, during catheter care and wound dressing changes, staff either omitted the gown or applied it incorrectly, and in some cases, failed to change gloves or perform hand hygiene between tasks or after glove removal. Staff also failed to properly disinfect shared equipment such as mechanical lifts after use, as observed when lifts were moved from resident rooms to hallways without cleaning. Additionally, there were lapses in hand hygiene practices, with staff not performing hand hygiene after glove removal, after handling soiled items, or before handling clean items. In several cases, staff changed gloves between tasks without washing or sanitizing their hands, and sometimes handled clean supplies or resident personal items with contaminated gloves. The report further documents failures in following specific infection control procedures during catheter care, such as not cleaning catheter connection sites with alcohol before connecting new tubing. Supplies used for wound care and insulin administration were not always sanitized before being returned to common storage areas. These deficiencies were confirmed through observation, record review, and staff interviews, with administrative staff acknowledging the expectation for proper hand hygiene, PPE use, and equipment disinfection.