Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene as required for residents with wounds, indwelling medical devices, or colonization with antibiotic-resistant bacteria. Observations revealed that staff did not consistently don gowns and gloves during high-contact care activities, such as repositioning, medication administration, and wound care, for multiple residents who required these precautions. For example, a nurse was observed handling a resident's urinary catheter and administering medications without donning a gown or performing hand hygiene, despite clear signage indicating the need for EBP. Another nurse administered medications to several residents consecutively without performing hand hygiene between residents. In several instances, staff either misunderstood or were unaware of the requirements for EBP. Nursing assistants entered a resident's room and repositioned the resident without wearing any PPE, despite EBP signage and the resident's need for such precautions due to stage 4 pressure ulcers and an indwelling catheter. Interviews with staff revealed gaps in knowledge regarding when to use gowns and gloves, and some staff believed PPE was only necessary when there was a risk of splashing bodily fluids. Additionally, for one resident with a recent surgical wound and an indwelling catheter, staff failed to provide gowns in the PPE cart and did not use gowns during high-contact care activities, as confirmed by both staff and the resident. The facility also failed to promptly implement EBP for newly admitted residents with indications for such precautions. One resident with a PICC line and a urinary catheter did not have EBP signage or PPE available for nine days after admission. Another resident receiving wound care did not have EBP signage or PPE available in their room, and staff did not implement EBP until after the deficiency was identified. These failures were confirmed through staff interviews and record reviews, which showed a lack of consistent adherence to infection prevention protocols as outlined in facility policy and CDC recommendations.