Failure to Maintain Enhanced Barrier Precautions and PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required enhanced barrier precautions due to wounds and skin breakdown. For one resident with multiple pressure ulcers, including stage 2 and stage 4 wounds, there was no enhanced barrier precaution signage or personal protective equipment (PPE) available outside or inside the resident's room following a room transfer. Staff were observed preparing to provide care without donning appropriate PPE until reminded by the wound care nurse, after which the necessary equipment was retrieved and signage was eventually posted. Another resident, who had a history of diabetes, neuropathy, limb amputations, and end-stage renal disease, also required enhanced barrier precautions for a skin opening and monitoring of a shunt/fistula site. However, PPE was not available inside or outside this resident's room as required by facility policy and physician orders. Interviews with staff and the infection preventionist revealed that the signage and PPE were not consistently maintained, particularly after room changes, and that there was confusion or lack of clarity regarding responsibility for ensuring these measures were in place. Record reviews confirmed that both residents had active orders for enhanced barrier precautions and that facility policy required PPE and signage for residents with wounds or indwelling devices. Despite in-service training and established policies, the facility did not consistently provide the necessary supplies or visual cues to support infection control practices, as evidenced by direct observations and staff interviews.