Failure to Monitor Refrigerator Temperatures and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly monitor and document the temperatures of personal refrigerators for two residents, as evidenced by missing temperature log entries for two consecutive days for each resident. Observations confirmed that the required daily temperature checks were not consistently performed, and staff interviews verified that the monitoring process was not followed as per facility policy, resulting in a lack of assurance that food was being stored safely for these residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for two residents who met the criteria for such precautions. One resident with an unhealed Stage III pressure ulcer did not have EBP in place, despite clinical documentation and physician orders indicating the need. Another resident with a physician order for contact isolation due to ESBL (E. Coli) of the urine was not provided with the correct isolation precautions, and staff were observed entering the room and administering medication without appropriate personal protective equipment or hand hygiene. These failures were confirmed by the facility's Infection Preventionist.