Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for residents requiring such measures, as evidenced by observations and record reviews. For one resident with multiple diagnoses including cerebral infarction, malnutrition, diabetes, hypertension, and two stage four pressure wounds, staff did not follow correct infection control procedures during a dressing change. The LPN performing the dressing change wore only gloves, did not change gloves between tasks, and used a bottle of normal saline with both dirty and clean gloves, contrary to infection control protocols. The LPN confirmed that only gloves were worn during the procedure, despite the care plan and physician orders specifying EBP. Additionally, another resident with multiple sclerosis, severe malnutrition, and several stage three and four pressure ulcers did not have the required EBP signage posted outside the room. Observations showed that staff providing incontinence, wound, and catheter care to this resident wore only gloves and did not use gowns as required by facility policy. Staff interviews confirmed that the appropriate PPE was not used and that the necessary signage was missing. The facility's policy mandates both gown and gloves for EBP and requires signage to be posted outside the resident's room.