Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement and maintain its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with certain medical devices. Several residents with percutaneous endoscopic gastrostomy (PEG) tubes and urinary catheters were not identified for EBP, and there was no signage or indicators in their rooms to alert staff and visitors of the required precautions. Additionally, personal protective equipment (PPE) was not readily available in these residents' rooms, and staff members were unaware of the need for EBP for residents with these devices. Observations revealed improper storage of oxygen nasal cannulas, with some found on the floor or wrapped around wheelchair handles, and not stored in a sanitary manner as per facility policy. Staff interviews confirmed a lack of awareness regarding proper storage procedures, and the facility's own policy required cannulas to be stored in plastic bags and replaced if contaminated. Furthermore, during blood glucose monitoring, a licensed nurse failed to place a barrier under the Accu-check monitor before setting it down in a resident's room and did not perform hand hygiene before donning gloves, contrary to facility policy and standard infection control practices. Staff interviews indicated gaps in knowledge and adherence to infection control protocols, including hand hygiene and the use of EBP for residents with urinary catheters and PEG tubes. Facility policies outlined the requirements for oxygen equipment management, EBP, and hand hygiene, but these were not consistently followed, leading to multiple deficiencies in infection prevention and control practices.