Failure to Implement Infection Control Practices for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for several residents on Enhanced Barrier Precautions (EBP). For one resident with a Foley catheter and a history of Parkinson's disease and cystostomy, a physical therapist assisted with transferring and repositioning without donning the required gown, only using gloves, and did not perform hand hygiene before leaving the room or entering another resident's room. The therapist stated he was aware of the EBP requirement but did not see the disposable gown, which was later found in the resident's closet. The facility's policy required both gown and gloves for high-contact care activities and hand hygiene before leaving the room. Another resident with a Foley catheter due to cancer and a recent history of sepsis and cholecystitis was also on EBP. A CNA provided direct care, including changing bed linens and assisting with hygiene, while only wearing gloves and not the required gown. The CNA acknowledged awareness of the EBP status but stated she only used the gown when emptying the catheter. The disposable gowns were available in the resident's closet, and both the Infection Preventionist and DON confirmed that proper PPE should have been used for all high-contact care activities as per facility policy. Additionally, a LVN failed to disinfect a shared blood pressure cuff after use with a resident, placing it back on the medication cart and then into a drawer without cleaning. The LVN admitted to not cleaning the equipment and acknowledged that shared equipment should be disinfected after each use. The facility's policy required reusable items to be cleaned and disinfected between residents. Another incident involved a LVN entering a resident's room, who was on EBP for a Foley catheter, and handling the catheter tubing without performing hand hygiene or donning gown and gloves, contrary to posted instructions and facility policy.