Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for a resident who was under Enhanced Barrier Precautions (EBP). Observations revealed that the resident, who had a pressure ulcer on the coccyx and an indwelling urinary catheter, did not have an EBP sign posted on or around her door during multiple checks. Staff members, including a CNA, a physical therapy assistant, a QMA, and an RN, were observed providing care to the resident while only wearing gloves, without donning gowns as required for high-contact care under EBP. Additionally, there was no PPE cart located next to the resident's room, and the resident's catheter bag was observed lying on the ground next to the bed. Interviews with staff indicated a lack of consistent understanding regarding the reasons for EBP and the required PPE. The infection prevention nurse confirmed that both gloves and gowns should be worn for high-contact care, but this was not followed in practice. Review of the facility's infection control policy showed that EBP was not addressed, and no other relevant policy was provided. These failures resulted in the facility not maintaining proper infection control practices for the resident on EBP.