Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance observed during surveyor review. During the morning medication pass, a medication aide did not clean the blood pressure cuff before or after use on three different residents, despite being aware of the requirement to disinfect equipment between residents. The aide acknowledged the lapse and confirmed knowledge of the facility's policy, which mandates cleaning with approved disinfectant wipes between each use to prevent cross-contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound during wound care. Two nurses performed wound care without wearing gowns, and one nurse's uniform came into contact with the resident's bedding. There was no signage indicating the need for EBP on the resident's door at the time of care. Both nurses later acknowledged that gowns should have been worn and that failure to do so could result in cross-contamination. Interviews with facility leadership, including the ADON, DON, and administrator, confirmed that equipment should be disinfected between residents and that EBP should be used for residents with wounds or indwelling devices during high-contact care activities. The infection control preventionist admitted uncertainty regarding EBP implementation and only placed appropriate signage after the surveyor's observation. Facility policy and CDC guidance provided to surveyors supported the need for these infection control measures.