Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene, during direct care for residents identified as requiring these measures. Observations revealed that three staff members, including nursing assistants and a physical therapist, did not consistently wear gowns and gloves as required during high-contact care activities for residents with wounds or other risk factors for multi-drug-resistant organisms. For example, during a transfer and linen change for a resident with cellulitis, lymphedema, and wounds, staff wore gloves but not gowns, and did not always change gloves or perform hand hygiene between tasks. Another resident with wounds and a history of falls was observed during room tidying and linen changes, where staff did not wear gloves or gowns as indicated by EBP signage and care plans. Staff were seen handling soiled linens, resident equipment, and personal items without appropriate PPE or hand hygiene. Interviews with staff revealed inconsistent understanding and application of EBP protocols, with some staff acknowledging lapses or uncertainty about when gowns and gloves were required. The facility's policy and care plans directed the use of EBP, including gowns and gloves, during high-contact activities such as dressing, bathing, transferring, and changing linens. However, documentation and staff interviews indicated that these protocols were not consistently followed, and order sets for residents requiring EBP lacked specific orders. The infection preventionist and nurse manager confirmed the expectations for EBP use, but observations and staff statements demonstrated gaps in adherence to infection control procedures.