Failure to Implement Enhanced Barrier Precautions and Proper Cohorting
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by improper implementation of Enhanced Barrier Precautions (EBP) and cohorting practices. A resident with an infected diabetic foot ulcer, confirmed to be colonized with multiple organisms including Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis, was placed under Contact Precautions. However, the resident's roommate, who had a PEG tube and therefore met criteria for EBP, did not have appropriate EBP signage posted. This omission was observed during a facility tour, and staff interviews confirmed that the required precautions were not in place for the roommate. The Unit Manager acknowledged the error, stating that after consultation with the Infection Preventionist, it was determined that the two residents should not have been cohorted together. The roommate was subsequently moved, and EBP signage was posted, but these actions occurred only after the deficiency was identified. The facility's own infection prevention and control policy required all staff to follow established procedures, which was not adhered to in this instance, resulting in a lapse in infection control practices.