Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP), appropriate personal protective equipment (PPE), and proper hand hygiene. Observations and staff interviews revealed that residents with indwelling medical devices and wounds were not consistently placed on EBP, and staff did not always use the required PPE during high-contact care activities. For example, one resident with a peripherally inserted central catheter (PICC) line was not on EBP, and the assigned LPN was unaware of the device, did not use a gown, and failed to perform hand hygiene after providing care and handling the PICC line. The dressing on the PICC line was also found to be loose and undated, further indicating lapses in infection control practices. Another resident with a stage four pressure ulcer was not provided care under EBP, as the CNA responsible for incontinence care did not wear an isolation gown despite PPE being available outside the room. The CNA acknowledged the requirement but stated she forgot to don the gown. Additionally, a third resident with diabetes received blood sugar monitoring and insulin administration from an LPN who failed to remove gloves or perform hand hygiene between tasks, including documenting in the electronic system and re-entering the resident's room with the same gloves. Review of facility policies and CDC guidance confirmed that EBP should be used for residents with wounds or indwelling medical devices, and that hand hygiene is required before and after glove use, as well as between resident contacts and after handling potentially contaminated items. The facility's failure to ensure adherence to these protocols was observed to affect at least three residents, as staff did not consistently follow established infection control procedures during care activities.