Failure to Implement Enhanced Barrier Precautions and Disinfection Protocols
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) and proper disinfection protocols, as observed during care of residents with open wounds and indwelling devices. On multiple occasions, staff did not don gowns or gloves when providing high-contact care, such as incontinence care, wound care, and catheter care, to residents who had open wounds or urinary catheters. For example, two CNAs transferred a resident with open wounds and provided incontinence care without wearing EBP gowns, and a licensed nurse performed wound care on the same resident without donning an EBP gown. Administrative staff confirmed that EBP should have been used in these situations, and facility policy required gown and glove use for such high-contact care activities. Additionally, staff failed to properly disinfect a blood glucose meter used for multiple residents. A licensed nurse was observed obtaining a blood sugar reading for a resident and then placing the glucometer back in a drawer without cleaning or disinfecting it. The facility had two glucometers in use for seven residents, and the manufacturer's instructions, as well as facility policy, required cleaning and disinfection of the device after each use. Administrative staff verified that the glucometer should have been disinfected between uses. One resident with a urinary catheter was also not provided care according to EBP protocols. A CNA emptied the resident's catheter bag without wearing gloves or a gown, despite signage and care plan instructions indicating that EBP should be used for catheter care. The CNA acknowledged the omission when questioned, and administrative staff confirmed that EBP was required for such care. These failures were in direct violation of the facility's infection prevention and control policies and placed residents at risk for infection.