Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Surveyors identified multiple failures by facility staff to follow standard infection control practices, specifically regarding Enhanced Barrier Precautions (EBP), hand hygiene, and glove use during care and medication administration. Several residents with conditions such as gastrostomy tubes, indwelling urinary catheters, pressure ulcers, wounds, and incontinence were observed to be on EBP, as indicated by signage and care plans. Despite these precautions, staff members, including nurses and CNAs, were repeatedly observed providing high-contact care activities—such as wound care, g-tube care, and incontinence care—without donning required gowns, and in some cases, without performing proper hand hygiene before or after care tasks. For example, staff provided g-tube care and administered medications to residents on EBP without wearing gowns, and wound care was performed without the use of gowns as required by facility policy. In several instances, staff wore gloves but failed to change them or perform hand hygiene between dirty and clean care tasks, such as during incontinence care and the application of ointments. These lapses occurred despite clear EBP signage and care plan instructions specifying the need for gloves and gowns during high-contact activities and the necessity of hand hygiene before entering and after leaving resident rooms. The facility's own EBP policy, last reviewed in April 2025, mandates the use of gowns and gloves for high-contact care activities for residents at increased risk for multidrug-resistant organisms (MDROs), including those with wounds, indwelling devices, or requiring extensive hands-on care. Staff interviews confirmed awareness of these requirements, yet observations revealed consistent non-compliance with established protocols, including failure to wear appropriate PPE and to perform hand hygiene at critical points during resident care.