Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that required signage indicating EBP was missing from the rooms of multiple residents with conditions such as dementia, colostomy, pressure ulcers, and indwelling catheters. In several cases, personal protective equipment (PPE) carts were not present either inside or outside the residents' rooms, despite physician orders and care plans specifying the need for EBP during high-contact care activities. Staff interviews confirmed awareness of the need for EBP but acknowledged the absence of signage and PPE carts, and the Director of Nursing (DON) was unaware that EBP required a PPE cart at each room. Additionally, the facility's infection control policy required signage to alert staff of precautions and the availability of PPE and alcohol-based handrub for staff. However, observations revealed that these requirements were not consistently met. For example, one resident with an indwelling catheter had a PPE cart near the bed but lacked appropriate signage, while another resident had signage but no PPE cart available. Staff interviews further revealed inconsistent understanding and implementation of EBP requirements, with some staff obtaining PPE from central supply rather than having it readily accessible at the point of care. In another instance, staff failed to don appropriate PPE while performing an invasive procedure, specifically the insertion of a peripheral IV for a resident with EBP orders and a care plan intervention explicitly listing IV sites as requiring PPE. The Assistant Director of Nursing (ADON) and other staff involved in the procedure did not use PPE, and the ADON stated that PPE was not typically used for IV initiation, despite the care plan's direction. The facility's infection control policy and care plans were not followed, resulting in lapses in infection prevention practices for residents at risk.