Failure to Implement Consistent Enhanced Barrier Precautions and Staff Training
Penalty
Summary
The facility failed to implement effective infection control practices for seven non-sampled residents who were under Enhanced Barrier Precautions (EBP) due to colonization with multidrug-resistant organisms (MDROs) such as CRE, C. auris, and CRAB. Observations revealed that EBP signs posted outside resident rooms were inconsistent and, in some cases, incorrect. For example, one room displayed a red sign requiring staff to wear an N-95 mask for a resident with CRE, which was not necessary according to facility policy. Other rooms had both standard EBP signs and additional colored signs (red or pink), each listing different PPE requirements, leading to confusion among staff. Interviews with staff, including LVNs, CNAs, RNs, and the Infection Preventionist (IP), demonstrated a lack of understanding regarding the meaning and requirements of the different colored isolation signs. Some staff incorrectly believed that an N-95 mask was required for EBP precautions, while others could not distinguish between the red and pink signs or their associated PPE protocols. The IP confirmed that the red and pink signs were intended to indicate additional infections and PPE needs but acknowledged that the signage was not always accurate and that staff training on the distinction between the signs was insufficient. Further review of training records showed that while staff had received general in-service training on EBP precautions, there was no documentation of specific training on the differences between the red and pink isolation signs. The lack of clear, consistent signage and inadequate staff training on EBP protocols resulted in improper implementation of infection control measures for residents colonized with MDROs.