Failure to Implement Enhanced Barrier Precautions and Annual Policy Review
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP), including the use of personal protective equipment (PPE) such as gowns and gloves, for three out of four sampled residents who required these measures. Observations revealed that residents with conditions such as MRSA colonization, urinary catheters, and wounds did not have appropriate signage or PPE available at their room entrances, and staff were not consistently using gowns and gloves during high-contact care activities. For example, one resident with MRSA and a history of osteomyelitis and gangrene had no EBP signage or PPE at their room, and a used bandage with bloody drainage was found on the floor. Another resident with a urinary catheter did not have EBP signage or PPE receptacles at their room, and the resident reported not recalling staff wearing gowns during care. A third resident with a urinary catheter also lacked EBP signage and PPE bins, and reported staff only wore gloves, not gowns, during catheter care. Interviews with staff revealed gaps in communication and awareness regarding which residents required EBP. The Infection Prevention nurse was unaware of a resident's new catheter placement because it occurred on a day they were not present, and stated that nurses were expected to implement EBP in their absence. The nurse also missed identifying a resident as an MRSA carrier. Despite claims of a system to identify residents needing EBP, these lapses resulted in inconsistent implementation of required precautions. Additionally, the facility's infection prevention policies, including those related to EBP, had not been reviewed annually as required. All reviewed policies had a last review date from over a year prior, and staff were unclear about who was responsible for ensuring the policies were kept current. This lack of timely policy review contributed to the risk of outdated procedures being followed.