Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures in multiple instances involving residents requiring special contact and droplet precautions, as well as Enhanced Barrier Precautions (EBP). In one case, a resident who tested positive for COVID-19 was on special contact and droplet precautions, as indicated by signage on the door and the availability of PPE supplies nearby. Despite this, a nurse aide entered the resident's room without donning gloves or a gown, moved a mechanical lift out of the room into the hallway without cleaning it, and later re-entered the room again without appropriate PPE to assist the resident. The mechanical lift was left unattended in the hallway until instructed by a unit manager to clean and store it properly. The nurse aide admitted to forgetting the required PPE and expressed confusion between different types of precautions, despite having received infection control training. In another instance, two nurse aides provided a bed bath and repositioned a resident with an indwelling urinary catheter, who was on EBP, while wearing gloves but not gowns. Both aides acknowledged during interviews that they were aware of the resident's precaution status and the need for gowns but failed to comply, attributing the lapse to forgetfulness. The Director of Nursing confirmed that all staff had received infection control training, especially following a recent COVID-19 outbreak, and that PPE supplies were adequate and available. Additional deficiencies were observed when a nurse aide provided care to a resident with a gastrostomy tube and another with a pressure ulcer, both on EBP, while only wearing gloves and not a gown. The aide also placed soiled linens on the floor instead of in a plastic bag, contrary to facility policy and her training. The aide admitted to not following protocol due to being rushed or not bringing the necessary supplies into the room. Interviews with supervisory staff confirmed that the expectation was for staff to follow posted EBP signage and infection control procedures, and that further education was needed.