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F0835
F

Failure to Train Staff and Implement Enhanced Barrier Precautions

Liberty, Texas Survey Completed on 06-04-2025

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

The facility failed to ensure that the Administrator, Director of Nursing (DON), and Infection Preventionist (IP) received training on Enhanced Barrier Precautions (EBP) as required by updated CMS and CDC guidance. Observations conducted over several days revealed that there was no EBP signage or personal protective equipment (PPE) set up outside or inside any resident rooms. Interviews with the ADON/IP and DON confirmed that they were not familiar with EBP, had not received training on the updated requirements, and were unaware of recent changes or provider letters regarding EBP implementation. The Administrator also indicated only a brief awareness of EBP and was not fully informed about the regulatory requirements. Record review indicated that the facility had residents with chronic wounds and indwelling medical devices, such as g-tubes and foley catheters, who were not placed on EBP during high-contact care activities. The lack of EBP implementation was confirmed through staff interviews and direct observation, with no evidence of EBP being practiced for any residents, regardless of their multidrug-resistant organism status. The facility's failure to train key staff and implement EBP protocols resulted in noncompliance with current infection control standards.

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