Failure to Follow Infection Control Program and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own infection prevention and control program for two residents. For one resident with severe mental impairment and a diagnosis of benign prostate hyperplasia, repeated observations showed that the resident's uncovered urinary drainage bag was in contact with the floor while the resident was seated in the dining room. Interviews with CNAs and the DON confirmed that the urinary bag and tubing should not touch the floor, as per facility policy, which specifically states not to place the drainage bag on the floor. For another resident with multiple diagnoses, including paraplegia and gastrostomy status, who had indwelling medical devices, the facility did not implement Enhanced Barrier Precautions (EBP) as required by CDC guidelines. Observations revealed no signage or PPE available for EBP outside the resident's room. Interviews with the Infection Preventionist and the DON indicated a lack of knowledge about EBP and confirmed that EBP had not been implemented for residents with indwelling medical devices, despite current regulatory guidance and facility policy requiring adherence to up-to-date infection prevention standards.