Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP) and hand hygiene assistance. For two residents on EBP due to the presence of invasive devices such as a PEG tube, PICC line, and indwelling urinary catheter, staff did not consistently don the required personal protective equipment (PPE) during high-contact care activities. In one instance, a CNA and an LPN repositioned a resident with a feeding tube while wearing gloves but not gowns, despite facility policy and care plans indicating that both gown and gloves were required for such activities. The staff involved were either unaware of the specific requirements or misunderstood when gowns were necessary. Additionally, another resident with a PICC line and catheter had linens changed by CNAs who did not wear any PPE, and an LPN managed the resident's PICC line with gloves only, omitting the gown. Staff interviews confirmed knowledge gaps and lapses in following EBP protocols. The report also documents failures in providing hand hygiene assistance to residents prior to meals. Three residents, each with varying levels of cognitive and physical impairment, were observed receiving meal trays without being offered or encouraged to perform hand hygiene. In each case, the CNA responsible for meal delivery did not assist or prompt the resident to clean their hands before eating. Interviews with the residents and staff confirmed that hand hygiene was not offered or performed prior to the meal service, despite facility policy and care plans indicating the need for such assistance, especially for residents with limited self-care abilities. The Director of Nursing acknowledged that staff were expected to offer hand hygiene assistance to all residents before meals and confirmed that infection prevention and control practices were not maintained during the observed meal service. The deficiencies were identified through policy review, medical record review, direct observation, and staff and resident interviews, highlighting specific instances where established infection control protocols were not followed.