Failure to Maintain EBP Signage and PPE for Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for three residents reviewed for infection control. Observations on multiple occasions revealed that required EBP signage was missing from the doors of rooms where EBP was indicated, and there was no equipment placed outside these rooms to alert staff of the necessary personal protective equipment (PPE) to be used. This was contrary to the facility's own policy and care plans, which specified that signage should be posted to inform staff of required precautions during high-contact care activities. Record reviews showed that the affected residents had significant medical conditions, including obstructive and reflux uropathy, malignant neoplasm of the kidney, sepsis, slow transit constipation, anemia, and heart failure. Their care plans required staff to use gowns and gloves during high-contact care and specified that EBP signage should be posted outside their rooms. However, during the survey, these signs were not present, and staff interviews confirmed reliance on such signage to determine appropriate PPE use before entering rooms. Staff interviews indicated that while in-service training on EBP and PPE had been conducted recently, staff depended on the presence of signage or equipment outside the room to guide their infection control practices. When signage was missing, staff reported they would consult with the nurse or infection preventionist. The infection preventionist acknowledged that EBP signs had been disappearing and required frequent replacement, but at the time of the survey, the necessary signage was not consistently in place for residents requiring EBP.