Failure to Implement Enhanced Barrier and Contact Precautions
Penalty
Summary
The facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and Contact Precautions for two residents, as observed through staff actions and resident behavior. For one resident with osteomyelitis and a PICC line, the care plan indicated EBP interventions, and facility policy required staff to don gown and gloves during high-contact activities such as transferring. However, staff were observed transferring the resident without wearing gowns, only using gloves and masks. Staff members stated they did not believe gowns were necessary if they did not touch the resident's PICC line, and this was reportedly confirmed by a staff nurse. The Director of Nursing Services stated that staff were expected to follow CDC guidelines and posted precaution signs during high-contact care activities. For another resident with a diagnosis of MRSA, the care plan required Contact Precautions, and signage instructed hand hygiene before entering and leaving the room. The resident was observed leaving the room multiple times without performing hand hygiene and used shared items, such as a staff pen, without cleaning hands. The resident stated they were unaware of the need for hand hygiene and did not believe they had MRSA. Staff, including the Infection Preventionist, confirmed that staff were expected to remind the resident to perform hand hygiene, but this was not observed to occur.