Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not following enhanced barrier precautions (EBP) for a resident requiring such measures. The resident in question was a male with severe cognitive impairment, total dependence for activities of daily living, and a gastrostomy tube, who was placed on EBP due to the presence of an indwelling medical device. Facility policy and CDC guidance required staff to wear gowns and gloves during high-contact care activities for residents on EBP. On several occasions, staff members, including an LVN and CNAs, provided high-contact care such as repositioning, perineal care, handling soiled linens, and G-tube care to the resident without donning the required personal protective equipment (PPE) such as gowns and gloves. Observations by the surveyor confirmed that staff failed to use appropriate PPE during these activities, despite EBP signage being posted above the resident's bed and PPE supplies being available in the room. Additionally, hand hygiene protocols were not consistently followed, as one CNA was observed not washing hands or using hand sanitizer after disposing of trash. Interviews with staff, including the wound care nurse, CNAs, LVN, ADON, DON, and the Medical Director, confirmed that they were aware of the EBP requirements and the need for PPE during high-contact care. However, despite this knowledge and the presence of visual cues, staff did not consistently adhere to infection control procedures. The facility had 23 residents on EBP at the time, and the failure to follow established protocols was directly observed and corroborated by staff interviews and record reviews.