Failure to Follow Enhanced Barrier Precautions and Proper Infection Control Procedures
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care activities for a resident with a gastrostomy tube. During medication administration through the gastrostomy tube, a nurse wore gloves but did not don a gown as required by EBP protocols, despite signage and PPE supplies being present outside the resident's room. The nurse stated she did not notice the precaution sign and did not realize the resident was on EBP, even though she had recently received infection control training. Additionally, the facility did not follow proper procedures for handling soiled linens and hand hygiene during incontinence care for another resident. Two nurse aides were observed placing soiled clothing and linens on the floor instead of directly into linen bags, which were available in the room. The aides also failed to remove contaminated gloves and perform hand hygiene before assisting the resident with dressing, transferring him to his wheelchair, and handling his personal belongings. Both aides acknowledged awareness of the correct procedures but did not follow them during the observed care. Interviews with staff, including the Infection Preventionist and the Director of Nursing, confirmed that education on infection control, EBP, and proper handling of soiled linens had been provided. Despite this, staff did not adhere to established protocols during the observed incidents, resulting in lapses in infection prevention and control practices for multiple residents.