Failure to Implement Effective Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program as required by its own policies. The facility’s Infection Prevention and Control Program policy required a system of surveillance for prevention, identification, reporting, investigation, and control of infections for residents, staff, volunteers, visitors, and others, with the Infection Preventionist (IP) responsible for leading surveillance activities, maintaining documentation, and reporting findings to the Quality Assessment and Assurance Committee. The policy also required that all staff receive training on the infection prevention and control program and demonstrate competence in relevant infection control practices. The Infection Preventionist policy required development and implementation of an ongoing infection prevention and control program and oversight of resident care activities. The Enhanced Barrier Precautions (EBP) policy required staff training on EBP, high‑risk activities, and organisms requiring EBP; obtaining EBP orders for residents with wounds and/or indwelling medical devices such as feeding tubes; making gowns and gloves available outside resident rooms; and periodic monitoring of adherence. Despite these policies, the IP was unable to provide documentation of ongoing infection surveillance audits or staff competency validations for the previous 12 months, producing only nine peri care/hand washing audit tools from a single month and stating she had not been auditing staff or was aware that routine surveillance auditing was required. The DON similarly reported that no formal infection control audits were conducted and could not produce any CNA infection control competency checkoffs. In addition to the lack of surveillance and competency documentation, staff failed to follow EBP requirements during direct resident care. A CNA provided hygiene care, including a brief change, to a resident who had multiple wounds and was receiving tube feeding, conditions that met the facility’s criteria for EBP, without donning a gown despite posted signage on the resident’s door and PPE available outside the room. The CNA confirmed she did not wear the required gown and stated she believed the resident did not have a condition requiring EBP precautions. The IP later stated she expected staff to wear PPE when providing direct contact with a resident on EBP, and the DON stated his expectation was that staff follow established protocols and use PPE as required, but acknowledged that leadership only conducted informal walk‑throughs without formal, documented infection control audits. These observations, interviews, and record reviews showed failures in consistent PPE use under EBP, failure to conduct required infection surveillance audits, and absence of documented staff infection control competency validation.
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