Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations revealed that a treatment nurse did not use the required personal protective equipment (PPE) beyond gloves while providing wound care to a resident with a sacral wound. Additionally, certified nursing assistants (CNAs) provided incontinent care to the same resident without using gowns or other PPE, and both staff members were unaware of the EBP requirements. There was also no EBP signage or PPE cart visible outside the resident's room during these care activities. Further review showed that two other residents, both with conditions requiring EBP (such as open wounds or indwelling catheters), also did not have EBP signage or PPE available outside their rooms. Staff members providing care to these residents were not informed about the need for EBP, and one CNA reported not receiving a report from the previous shift regarding necessary precautions. The facility's policy required the use of gowns and gloves for high-contact care activities for residents with wounds or indwelling devices, but this was not consistently communicated or implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it was their expectation and responsibility to ensure proper signage, PPE availability, and staff awareness for residents requiring EBP. However, these measures were not in place for the residents reviewed, resulting in a failure to follow the facility's own infection control policy and potentially increasing the risk of communicable disease transmission among residents and staff.