Failure to Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Staff failed to follow established infection prevention and control protocols, specifically Enhanced Barrier Precautions (EBP), during high-contact care activities for two residents with wounds and indwelling catheters. Despite clear physician orders and care plans requiring the use of gowns and gloves during such activities, observations revealed that staff only donned gloves and omitted gowns while performing wound care and transfers. EBP signage and supply bins were present, but staff did not consistently adhere to the required use of personal protective equipment (PPE) as outlined in facility policy and CDC/CMS recommendations. Additionally, the facility did not maintain proper management of catheter drainage bags. On multiple occasions, a resident's catheter drainage bag was observed lying on the floor and not placed in a privacy bag, contrary to facility policy. Interviews with staff indicated a lack of clarity regarding the location of privacy bags and inconsistent understanding of proper catheter bag handling, despite recent training. Staff acknowledged that drainage bags should not touch the floor and should be covered, but these practices were not followed during the survey. The facility also failed to ensure food safety standards were met when a dietary aide transported uncovered plated food on a cart via the elevator. The administrator confirmed that food should be covered during transport, but observations showed several plates without lids. These lapses in infection control and food safety practices were directly observed and confirmed through staff interviews and record reviews.