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F0880
D

Failure to Follow Enhanced Barrier Precautions During Resident Care

Upland, California Survey Completed on 06-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow required infection control practices while providing care to a resident under Enhanced Barrier Precautions (EBP) isolation. The resident had been admitted with a history of digestive system surgery and required ongoing care for a gastrostomy tube, with physician orders specifying the use of gloves and gown during high-contact care activities. Despite clear signage indicating EBP isolation and explicit orders for PPE use, the LVN entered the resident's room and performed treatment without donning the required isolation gown. During interviews, the LVN acknowledged the failure to wear the appropriate PPE and recognized the lapse in protocol. The Infection Preventionist Nurse confirmed that all staff are expected to use PPE when caring for residents under isolation precautions, and the Director of Nursing reviewed the facility's policy, which mandates gown and glove use for residents under EBP. The facility's policy was not followed during this incident, as confirmed by the DON.

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