Failure to Maintain Infection Control Practices and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care and when implementing Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices. During wound care for a resident with a Stage III left heel pressure wound, a nurse did not clean the work surface or place a barrier before setting wound care supplies on the resident's dresser, and did not place a barrier under the resident's heel, allowing the wound to come into contact with the floor. The nurse acknowledged not following clean technique and stated she did not think to use a barrier, despite having received infection control training. Additionally, staff did not consistently implement the facility's infection control policy for EBP. One nurse performed a PICC line flush for a resident on EBP while wearing gloves but not a gown, despite an EBP sign being present and PPE supplies available. The nurse was aware of the EBP status but was uncertain about the requirement to wear a gown. Another nurse aide assisted a resident with a Stage III heel wound, also on EBP, without wearing gloves or a gown. There was no EBP sign on the resident's door, and gowns were not available in the room, leading the aide to be unaware of the need for EBP. Interviews with the Infection Control Preventionist Nurse and the Wound Nurse revealed that responsibility for ensuring EBP signage and PPE availability was shared among staff, but oversights occurred, resulting in the absence of required signage and supplies. The administrator confirmed that staff had received annual infection control training, but the observed staff did not follow the facility's infection control measures or EBP policy during the incidents.