Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures, specifically regarding the use of Enhanced Barrier Precautions (EBP) for residents at increased risk of multidrug-resistant organism (MDRO) transmission. Multiple residents, including those with indwelling urinary catheters, feeding tubes, IV lines, and those receiving intravenous antibiotics, did not have EBP signage posted at or near their rooms to inform staff of the required personal protective equipment (PPE) during high-contact care activities. Observations confirmed the absence of EBP signage for several days after admission for these residents, despite facility policy and staff statements indicating that such signage should be in place for residents with these risk factors. Staff interviews revealed that the process for posting EBP signage was disrupted due to the absence of the Admissions Nurse, resulting in a breakdown of the admission process and failure to ensure signage was consistently placed. Staff members, including a nurse manager and infection preventionist, acknowledged the lack of signage and confirmed that it should have been present for the affected residents. The absence of EBP signage meant that staff were not consistently reminded to use gowns and gloves during high-contact care, as required for residents with wounds, indwelling devices, or those receiving certain treatments. Additionally, the facility failed to ensure proper hand hygiene practices during medication administration. An observation of a nursing technician administering medications and topical ointment to a resident showed that the staff member did not use hand sanitizer after removing gloves or upon entering and leaving the resident's room. The staff member acknowledged forgetting to perform hand hygiene, and the director of nursing confirmed that the expectation was for staff to perform hand hygiene after glove removal and between residents.