Failure to Consistently Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
During an abbreviated survey, the facility failed to ensure that enhanced barrier precautions were consistently followed by staff for two out of three residents reviewed for infection control. In one instance, two Certified Nurse Aides provided care to a resident with wounds requiring dressing changes, who was on enhanced barrier precautions, without donning gowns as required by facility policy. The resident confirmed that staff sometimes wore gowns and sometimes did not. Both aides stated they were unaware the resident was on enhanced barrier precautions, citing lack of report and information. The enhanced barrier sign was present outside the room, but staff did not recognize or follow the protocol until it was pointed out during the survey. In another case, a resident with an indwelling Foley catheter and severe cognitive impairment was observed walking from their room to the nurse's station carrying their drainage bag by hand, without a leg bag in place. Staff interviews revealed that the resident routinely carried the drainage bag and had not been observed with a leg bag, despite staff awareness that a leg bag should be used during the day. The LPN and Certified Nurse Aide involved indicated that the resident did not comply with the use of a leg bag, and the care plan noted the resident was encouraged to use one. The facility's infection control policy, last revised in April 2024, requires enhanced barrier precautions, including targeted gown and glove use, for residents at increased risk for multidrug-resistant organisms. The policy applies to all employees providing care. However, the survey found lapses in communication and adherence to these protocols, as staff were either not informed or did not follow the required precautions during high-contact care activities for residents on enhanced barrier precautions.