Failure to Adhere to Enhanced Barrier Precautions and Environmental Cleaning
Penalty
Summary
Staff failed to follow infection prevention practices related to the use of personal protective equipment (PPE) and cleaning of shared equipment for residents on enhanced barrier precautions (EBP). A certified nursing assistant (CNA) was observed transferring multiple residents using a mechanical lift without wearing a gown, despite clear signage and available PPE indicating that gown and glove use was required for residents on EBP. The CNA also failed to clean the lift after each resident use, as required by facility policy and confirmed by interviews with other staff members. Multiple residents on EBP, due to conditions such as wounds, feeding tubes, or multi-drug resistant organisms (MDROs), reported that staff typically wore gloves but not gowns during care and transfers. Additionally, the report documents that urinals without lids were used and left in resident rooms, and that a spill of urine on the floor in one resident's room was not cleaned for approximately two hours. The resident expressed concern about the unaddressed spill, and staff were unaware of the issue until it was brought to their attention. Observations confirmed the presence of urine on the floor, and urinals without lids were noted in the room. The infection preventionist and director of nursing confirmed that urinals should have lids unless otherwise care planned, and that environmental cleanliness is expected. Review of facility policies confirmed that EBP requires gown and glove use during high-contact care activities for residents with wounds, indwelling devices, or MDROs, and that shared equipment such as lifts must be cleaned after each use. The observed and reported failures to adhere to these policies resulted in deficiencies in infection prevention and environmental cleanliness for multiple residents.