Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices, specifically regarding hand hygiene and the use of Enhanced Barrier Precautions (EBP) during resident care for two out of three residents reviewed. Observations and record reviews revealed that staff did not consistently follow EBP protocols, such as wearing gowns and gloves during high-contact care activities, and did not always perform hand hygiene at required times, including between glove changes. The facility's own policies and posted signage required these precautions for residents with indwelling catheters, wounds, or pressure ulcers, but these were not always adhered to during care activities such as transferring, grooming, and catheter care. One resident with severe cognitive impairment, a suprapubic catheter, and a history of urinary tract infection was observed receiving care where staff initially followed infection control practices but failed to don gowns during subsequent high-contact activities like transferring and grooming. Another resident with an indwelling catheter, pressure ulcer, and multiple comorbidities was observed during care where staff changed gloves without performing hand hygiene, contrary to facility policy and CDC guidelines. Documentation also showed lapses in recording EBP implementation for this resident during certain shifts. Interviews with the Interim Director of Nursing and the Administrator confirmed that staff were expected to follow EBP protocols, including the use of gowns and gloves for high-contact care and hand hygiene between glove changes. However, direct observations and record reviews demonstrated that these expectations were not consistently met, resulting in a failure to fully implement the facility's infection prevention and control program as required.