Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program based on direct observations, staff interviews, and record reviews involving two residents. One resident with a Foley catheter and multiple diagnoses, including Parkinson's disease and urinary retention, received perineal care from two CNAs who failed to perform hand hygiene between glove changes. The CNAs changed gloves multiple times during care, touched various clean and contaminated surfaces, and only performed hand hygiene after leaving the resident's room, contrary to facility policy. Another resident with a PEG tube and Parkinson's disease received pericare from an LPN who did not wash hands before donning gloves and did not wear a gown, despite the resident's use of an indwelling medical device. There was also no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the resident's room, as required by facility policy. The LPN stated a misunderstanding of when gown use was necessary, believing it was only required if the resident was sick. Facility policies reviewed by surveyors clearly outlined the need for hand hygiene before and after glove use, the use of gowns and gloves during high-contact care activities for residents with indwelling devices, and the posting of EBP signage and availability of PPE. Both direct care staff and the Director of Nursing confirmed during interviews that the observed practices did not align with facility policies and procedures.