Failure to Maintain Enhanced Barrier Precautions and Update Infection Control Policies
Penalty
Summary
The facility failed to ensure staff consistently maintained standard and enhanced barrier precautions (EBP) during resident care and did not review or revise infection prevention and control policies annually. Observations revealed that staff provided high-contact care to a resident with a wound without donning required gowns, despite posted EBP signage and a care plan specifying this requirement. Staff involved were unaware of the resident's wound status and the necessity for gowns, even though the infection preventionist later confirmed the resident did have a wound requiring such precautions. In another instance, a nurse performed a dressing change for a resident with a stage 3 pressure ulcer without wearing a gown, despite EBP signage and the infection preventionist's confirmation that gown and glove use was required for such cases. The nurse admitted uncertainty about EBP requirements during the surveyor's inquiry. Additionally, a nurse was observed preparing and priming an intravenous line and pump for another resident without wearing gloves, failing to adhere to standard infection control precautions. The facility's Director of Nursing acknowledged that infection prevention and control policies had not been reviewed or updated in the past year, and no documentation was available to demonstrate that policies had been evaluated or revised based on the current facility assessment or resident population. The policies provided were outdated, generic, and lacked facility-specific information.