Failure to Adhere to Enhanced Barrier Precautions and Proper Disinfection of Shower Facilities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) and improper cleaning and disinfection of shower facilities. For two residents on EBP due to wounds and pressure ulcers, staff did not consistently wear the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities. Observations revealed that staff entered rooms and provided care, including transferring residents and changing briefs, without donning the appropriate PPE, despite clear signage and care plans indicating the necessity of EBP for these residents. Interviews with staff confirmed a lack of understanding or adherence to the EBP requirements, with some staff incorrectly believing that gowns were only needed for certain activities or that the signage applied to other residents. Additionally, the facility did not ensure that shower facilities and equipment were properly cleaned and disinfected between residents. In one instance, a shower chair was found with dried brown matter, and a staff member acknowledged that it had not been cleaned after previous use. Another observation documented a strong odor of feces and visible fecal matter on the shower floor after a resident's shower. The staff member removed the feces but did not use any cleaning or disinfectant products before bringing another resident into the same shower stall. The staff member admitted to not using disinfectant after every resident, contrary to facility policy and infection control standards. The facility's own policies required the use of PPE during high-contact care for residents on EBP and mandated cleaning and disinfection of reusable equipment and shower areas between residents. Despite these policies, direct observations and staff interviews demonstrated repeated failures to follow established infection prevention protocols, resulting in deficiencies in both resident care and environmental sanitation.