Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) and proper infection control practices during resident care, as evidenced by multiple observations and interviews. For several residents with indwelling medical devices such as gastrostomy tubes and urinary catheters, there was a lack of EBP signage, absence of personal protective equipment (PPE) outside rooms, and missing physician orders for EBP. Staff were observed providing care without appropriate PPE, and some were unaware of the requirements for EBP during high-contact activities, such as dressing changes and hygiene care. In one instance, a sign was incorrectly placed above the wrong bed, and a PPE basket was missing due to being broken and not replaced. During incontinence care, staff did not follow proper perineal cleansing techniques. One CNA was observed not cleansing the inner labia as required, and both the skills checklist and facility policy lacked specific instructions on how to perform perineal care. The Director of Nursing confirmed that the policy and competency documents did not provide detailed guidance, and staff training was insufficient in this area. This resulted in incomplete hygiene practices for residents requiring incontinence care. Additionally, improper infection control practices were observed during wound care for a resident with multiple wounds, including a Stage III pressure ulcer. Staff used the same gloves for different tasks, such as cleansing the perineal area and then handling the wound and clean supplies, which could lead to cross-contamination. Dirty linens were also left on the floor instead of being properly bagged. These lapses in infection prevention and control affected multiple residents and were confirmed through interviews, observations, and policy reviews.