Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices involving both staff and a resident. Specifically, a certified nursing assistant (CNA) did not sanitize her hands between passing and setting up meal trays for residents, only sanitizing before starting the task and not between each resident. This was confirmed through observation and interview, where the CNA acknowledged not considering the need for hand hygiene between residents. Additionally, two CNAs performed foley and incontinent care for a resident with an indwelling catheter and G-tube without wearing the required personal protective equipment (PPE) and without enhanced barrier precaution (EBP) signage on the resident's door, as required by facility policy. The resident involved had severe cognitive impairment, was dependent on all activities of daily living, and required enhanced barrier precautions due to the presence of medical devices. Both CNAs involved in the care were unaware of the resident's EBP status and did not use appropriate PPE during high-contact care activities. Facility policies reviewed indicated clear requirements for hand hygiene before and after handling food and for the use of gloves and gowns during care of residents on EBP, including posting appropriate signage. These deficiencies were confirmed through staff interviews and record reviews.