Failure to Provide Mandatory EBP Training for Staff
Penalty
Summary
The facility failed to ensure that mandatory training on infection prevention and control, specifically Enhanced Barrier Precautions (EBP), was provided to 11 of 12 employees reviewed, including both new and existing staff such as the Administrator, DON, ADON/IP, LVNs, and CNAs. Record review indicated that education on EBP was only conducted after surveyor intervention, and prior to this, staff had not received adequate training on the facility's written standards, policies, and procedures for EBP. The facility's policy required implementation of EBP for residents with certain conditions, such as wounds or indwelling medical devices, but staff were not familiar with these requirements before the surveyor's involvement. Observations and interviews revealed that staff members, including CNAs and LVNs, were unable to accurately describe EBP or differentiate it from other types of precautions, such as Transmission-Based Precautions (TBP) or standard precautions. During incontinent care for a resident with a g-tube, CNAs donned gloves but did not use gowns as required by EBP, and there was no signage indicating EBP in the resident's room. Multiple staff members expressed uncertainty about what EBP entailed, when it should be used, and whether they had received training on it. Some staff confused EBP with the use of barrier creams or standard infection control practices, and several stated they were unsure if any residents were currently on EBP. Interviews with facility leadership, including the ADON/IP and DON, confirmed that they had not been trained on EBP prior to the survey and were unaware of recent updates or changes in infection control guidelines. The ADON/IP stated she relied on the DON and Administrator for updates, while the DON reported difficulty accessing training opportunities and was unable to articulate expectations related to EBP. The Administrator acknowledged responsibility for infection control education but indicated that staff were only educated on EBP after surveyor intervention. The lack of staff training on EBP and the facility's failure to implement its own policy placed residents at risk of illness due to inadequate infection control practices.