Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Environment
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Despite having a policy that required EBP for residents with wounds or devices such as urinary catheters and feeding tubes, staff did not consistently apply these precautions. Observations revealed that on four of six units, EBP was not implemented, and staff did not use personal protective equipment (PPE) when providing high-contact care activities such as wound care, catheter care, and tube feeding. Multiple residents with wounds, indwelling catheters, or feeding tubes did not have EBP signage or PPE available, and staff were observed providing care without donning gowns or gloves as required by facility policy. Interviews with staff and leadership indicated a lack of understanding and inconsistent application of the EBP policy. The Director of Nursing (DON) and unit managers stated that EBP was only applied to residents with known multidrug-resistant organisms (MDROs) or those in proximity to such residents, contrary to the facility's written policy and CDC guidelines. Staff members, including CNAs, LPNs, and activity aides, demonstrated confusion about when PPE was required and were observed entering rooms and providing care without appropriate infection control measures. Documentation in care plans and Kardexes also failed to instruct staff to use PPE for residents who met EBP criteria. Additionally, the facility did not maintain a sanitary environment in the laundry department. The only sink in the contaminated laundry area was non-functional for one to two weeks, leaving staff without a means to perform hand hygiene after handling soiled laundry and removing PPE. Staff reported using a sink in the employee break room across the hall, which required leaving the contaminated area before performing hand hygiene, in violation of the facility's own laundry policy and standard infection control practices.