Failure to Follow Enhanced Barrier Precautions for Resident on Infection Control Protocol
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for one resident who was under Enhanced Barrier Precautions (EBP). Specifically, staff members did not consistently don the required personal protective equipment (PPE) before entering the resident's room and providing care. Video footage confirmed that on two separate occasions, a licensed vocational nurse (LVN) and a certified nursing assistant (CNA) entered the resident's room without wearing the appropriate gown and gloves, despite clear signage and available PPE supplies outside the room. The resident involved was an older male with multiple complex medical conditions, including Parkinson's disease with dyskinesia, type 2 diabetes mellitus, and a feeding tube due to dysphagia. His care plan and medical records indicated the need for EBP, which required staff to wear gowns and gloves during high-contact care activities, such as medication administration and incontinent care. Observations showed that PPE and hand hygiene supplies were accessible, and signage was posted to instruct staff on the required precautions. Interviews with various staff members, including CNAs, LVNs, and nursing leadership, revealed that they were aware of the EBP requirements and the importance of PPE use to prevent infection and cross-contamination. Despite this knowledge and ongoing in-service training, the observed failures by the LVN and CNA to don PPE before providing care to the resident constituted a breach of the facility's infection control policy.