Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control protocols for two of three residents reviewed, specifically in relation to Enhanced Barrier Precautions (EBP) as outlined by the CDC. For one resident with diabetes and severe, weeping edema in both lower extremities, there was a physician order for EBP during high-contact care activities. However, the resident's care plan did not include a focus on EBP, and there was no EBP signage or PPE holder on the door. Observations confirmed the resident had dressings and bandages on his legs, but staff did not have the necessary reminders or equipment available to follow EBP protocols during care, despite ongoing symptoms of weeping edema and a history of sepsis. Another resident with a Foley catheter and wounds on his lower extremity had a care plan that included EBP during direct contact with ADL care. During an observed transfer using a Hoyer lift, one CNA donned gloves but not a gown, and another CNA did not use any PPE. Both CNAs assisted with high-contact activities such as transferring, changing clothing, and handling the resident's catheter without following EBP requirements for gown and glove use. The staff later acknowledged that EBP protocols should have been followed due to the resident's catheter and wounds. The facility's policy required clear signage, availability of gowns and gloves outside resident rooms, and adherence to EBP for residents with wounds or indwelling devices. Despite these requirements, observations and interviews revealed lapses in both staff knowledge and practice, as well as missing care plan interventions and lack of proper signage and PPE accessibility. These failures resulted in noncompliance with infection control standards for residents at increased risk of multidrug-resistant organism transmission.