Failure to Implement and Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for three out of twenty-six sampled residents. Staff were observed not donning required Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), not performing hand hygiene during dressing changes, and engaging in cross-contamination during a central line dressing change. Specifically, signage for PPE requirements was inconsistently marked, and staff demonstrated confusion regarding when and what type of PPE was necessary for care activities involving residents with indwelling devices or wounds. For one resident with a central line for IV antibiotic administration due to infective endocarditis, staff did not wear a gown during medication administration or dressing changes, despite EBP policy requiring both gown and gloves for such high-contact care. Additionally, hand hygiene was not performed prior to donning sterile gloves, and improper technique was used when cleaning the central line insertion site, with the nurse going back over the insertion site after cleaning outward. The PPE signage outside the resident’s room was not properly marked until after the dressing change, and staff interviews revealed a lack of understanding about EBP requirements. Other residents with wounds, feeding tubes, or indwelling urinary catheters also had EBP signage posted, but staff were observed providing care and assistance, including transfers and therapy, without donning the required PPE. Interviews with staff indicated inconsistent knowledge and application of EBP protocols, and in some cases, there were no physician orders for EBP found in the records. The facility’s policy required gown and gloves for high-contact care activities for residents with wounds or indwelling devices, but these procedures were not consistently followed.