Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Multiple residents with conditions such as suprapubic catheters, gastrostomy tubes, foley catheters, and pressure ulcers did not have EBP signage posted outside their rooms, and personal protective equipment (PPE) was not set up or readily accessible prior to staff entering the rooms. Observations revealed that staff did not consistently wear gowns or follow EBP protocols during high-contact care activities, such as catheter care, wound care, medication administration via g-tube, and resident transfers. In several instances, staff only wore gloves and did not don gowns, even when their uniforms came into direct contact with residents or their bedding during care. Interviews with staff, including CNAs and LVNs, indicated a lack of understanding and training regarding EBP and the distinction between EBP and other types of precautions. Some staff believed EBP referred to the use of barrier creams or setting up towels, and were unsure about which resident care activities required EBP. Staff also reported not receiving recent or adequate training on EBP, and some were unaware of the updated CDC recommendations or facility policies regarding EBP. The infection preventionist and DON also demonstrated limited knowledge of EBP requirements and did not identify any residents as currently needing EBP, despite the presence of qualifying conditions among several residents. Record reviews further showed that care plans and physician orders for affected residents did not include instructions for EBP, and the facility's own policy on EBP was not being followed in practice. The lack of EBP implementation was observed across multiple days and for several residents, with repeated failures to post signage, provide PPE, and ensure staff compliance with gown use during high-contact care. These deficiencies were confirmed through direct observation, interviews with staff and residents, and review of facility documentation.