Failure to Implement and Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff practices and lack of proper implementation of enhanced barrier precautions (EBP) for residents with wounds or indwelling devices. One incident involved a certified nursing assistant (CNA) who did not change gloves or perform hand hygiene appropriately while providing incontinent care to a resident with cerebral palsy and frequent incontinence. The CNA used the same gloves to clean the resident, apply a clean brief, assist with dressing, handle the resident's wheelchair and walker, search through drawers, and brush the resident's hair, before finally removing the gloves and performing hand hygiene outside the room. The CNA acknowledged the lapse and understood the correct procedure, attributing the failure to nervousness. Interviews with facility leadership confirmed that glove changes and hand hygiene are required at specific points during care, and that failure to do so could result in infection and cross-contamination. Another deficiency was observed during wound care for a resident with dementia, chronic heart failure, and chronic kidney disease. The treatment nurse and the DON entered the resident's room to provide wound care without donning gowns, and only wore gloves. There was no EBP signage on the door, nor was there a PPE cart available outside the room. The resident's care plan did not include EBP, and there was no physician order for EBP in the resident's medical record. The facility's policy requires EBP for residents with wounds or indwelling devices, and communication to staff should occur via postings and electronic records. Additionally, another resident with chronic kidney disease and impaired cognitive function did not have EBP signage or a PPE cart outside her room, despite having orders for wound care. Observations on multiple occasions confirmed the absence of required signage and PPE. Interviews with the ADON, Administrator, and DON revealed that nursing management was responsible for ensuring EBP signage and PPE carts were in place, but these measures were not implemented. The DON admitted to forgetting to follow up on obtaining PPE carts. Facility policies reviewed indicated that EBP should be used for residents with wounds or indwelling devices, and that staff should be notified through postings and electronic records.