Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection control practices, specifically Enhanced Barrier Precautions (EBP), for three residents with conditions requiring such measures. For one resident with a history of septicemia, hip fracture, paraplegia, and a pressure ulcer, staff were observed performing wound care without all team members donning the required personal protective equipment (PPE). During the procedure, a CNA did not wear a gown while assisting with care, and an LPN used the same gloves to touch potentially contaminated surfaces and then cleanse the wound bed, contrary to infection control protocols. Multiple staff interviews confirmed the expectation that all care team members should wear PPE, including gowns and gloves, when providing care to residents requiring EBP. Another resident with multiple pressure ulcers and a history of infections was observed receiving wound care from an LPN and a nurse practitioner. During the dressing change and debridement, neither staff member wore a gown as required by the resident's care plan and facility policy for EBP during high-contact care activities. The care plan specifically directed the use of gown and gloves for such procedures due to the presence of wounds. A third resident with quadriplegia and impaired skin integrity was observed receiving wound care without the staff member wearing a gown or changing gloves between dirty and clean tasks. The care plan and physician's orders required EBP, including gown and gloves, for high-contact care activities due to wounds and an indwelling medical device. Staff interviews and policy review confirmed the expectation for PPE use and proper glove changes during wound care. The facility's infection control policy outlined the need for EBP to prevent the spread of multi-drug resistant organisms, but these practices were not consistently followed during the observed care activities.