Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling catheters and other risk factors. Certified Nursing Assistants (CNAs) providing incontinent and catheter care to one resident did not perform hand hygiene or change gloves between dirty and clean tasks, and used the same gloves and wipes for multiple care activities, including handling clean briefs and linens. The CNAs also did not wear gowns as required for EBP, and there was no EBP signage or PPE cart outside the resident's room at the time of care. The CNAs acknowledged their failure to follow proper infection control procedures and stated that they were only provided gowns after informing a nurse that a surveyor would be observing care. Another resident with an indwelling catheter and EBP orders also did not have the required EBP signage or PPE cart outside her room. Staff assigned to this resident were unaware of the need to use gowns and gloves during care activities, and did not use the appropriate PPE. The charge nurse for this resident confirmed awareness of the EBP order but did not ensure the necessary signage or PPE cart was in place, only realizing the omission when questioned by the surveyor. The signage and cart were only placed outside the room after the deficiency was identified during the survey. Interviews with facility leadership, including the Director of Nursing (DON), Infection Preventionist (IP) nurse, and interim Administrator, revealed that they were not aware that the required EBP signage and PPE carts were missing for these residents. The facility's policies required hand hygiene, glove changes between dirty and clean tasks, and the use of gowns and gloves for residents on EBP during high-contact care activities. The IP nurse stated she was responsible for ensuring signage and PPE availability but was unaware of the lapses until the survey. The DON and Administrator confirmed expectations for proper infection control practices, which were not met in these instances.