Failure to Implement Enhanced Barrier Precautions and Proper Infection Control During High Contact Care
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for residents with indwelling medical devices during high contact care activities, as observed with two residents. One resident with a tracheostomy and PEG tube had clear signage indicating EBP requirements, including the use of gloves and gowns for specific care activities. However, a registered nurse was observed entering the resident's room on two occasions to perform high contact care activities, such as administering medications through the PEG tube and providing tracheostomy care, while only wearing gloves and not a gown. The nurse's uniform came into direct contact with the resident during these activities, and both the nurse and the Director of Nursing confirmed that a gown should have been worn for these procedures. Another resident with a suprapubic catheter and chronic wounds was also not provided with proper EBP. There was no signage on the resident's door indicating EBP status, and a certified nursing assistant performed catheter care and emptied the drainage bag while only wearing gloves, not a gown. The assistant placed clean and used washcloths on a nightstand that had visible brown dried substances, and used the same washcloth to clean both the suprapubic catheter site and the drainage bag port, resulting in cross-contamination. The assistant was unaware that the resident was on EBP and that a gown was required for high contact care activities, and acknowledged the potential for cross-contamination during the interview. The Infection Control Coordinator initially expressed uncertainty about the need for EBP for residents with suprapubic catheters, but later confirmed that EBP should be used for all high contact care activities for such residents. Facility policies reviewed did not specify the need to ensure bedside stands were clean before placing equipment, and the policy for emptying urinary drainage bags required wiping the port with an alcohol swab, which was not followed. CDC guidance and facility policy both require EBP for residents with wounds or indwelling medical devices, including the use of gloves and gowns for high contact care activities, and posting appropriate signage, which was not consistently implemented.