Failure to Implement Enhanced Barrier Precautions and Maintain PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors, including wounds, indwelling medical devices, and incontinence. The resident had a complex medical history, including pemphigus vulgaris and Stevens-Johnson Syndrome, resulting in multiple skin lesions, a pressure ulcer, and a feeding tube. Despite physician orders and care plans indicating the need for EBP, staff did not consistently implement these precautions during high-contact care activities. Multiple interviews with staff revealed a lack of awareness and understanding of EBP, with several CNAs and nurses stating they only used gloves and did not recognize which residents required EBP. PPE such as gowns and gloves were not readily available in the designated resident halls, and signage indicating EBP requirements was either absent or limited to small CDC pocket guides, which staff often did not notice. Some staff reported not receiving orientation or training on EBP, and there was confusion between EBP and isolation/contact precautions. Additionally, supply checks for PPE were inconsistent, with empty containers and drawers observed during the survey. Leadership interviews confirmed that there had been no recent staff training on EBP, and monitoring of PPE availability was not reliably performed. The infection control policy required clear signage, accessible PPE, and staff education, but these measures were not fully implemented. The deficiency was identified through observations, interviews, and record reviews, demonstrating a systemic failure to follow established infection control protocols for residents at risk of MDRO transmission.