Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
Staff failed to follow standard infection prevention and control practices for all sampled residents on enhanced barrier precautions (EBP). Observations revealed that staff, including certified medication aides, LPNs, RNs, and housekeepers, did not consistently wear required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. These activities included transferring residents, providing hygiene, changing linens, and device care for residents with indwelling devices, wounds, or infections. In several instances, PPE was not visible or accessible, and staff were observed performing care without donning appropriate protective gear, despite clear signage and policy requirements. Multiple staff members were observed not performing hand hygiene at critical moments, such as before and after resident contact, after glove removal, and before handling clean supplies or equipment. Staff were also seen using the same gloves for multiple tasks, touching clean supplies with contaminated gloves, and failing to clean equipment and personal items after use in EBP rooms. In some cases, staff expressed uncertainty about the reasons for EBP or the correct procedures for hand hygiene and PPE use, despite existing policies and posted instructions. Residents involved had significant risk factors, including indwelling urinary catheters, feeding tubes, wounds, and histories of multidrug-resistant organism (MDRO) infections or urinary tract infections. The facility's own policies required sterile technique for certain procedures, such as urinary catheter flushing, and mandated that soiled linens be bagged at the point of care. However, staff were observed using non-sterile containers for sterile solutions, transporting soiled linens without proper containment, and storing clean supplies inappropriately. Interviews with facility leadership confirmed expectations for compliance with infection control policies, but direct observations and staff interviews demonstrated widespread noncompliance.