F0880

F

Failure to Implement EBP, Maintain Aseptic Care Practices, Disinfect Equipment, and Complete TB Screening

Kirkwood, Missouri Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified multiple infection prevention and control deficiencies involving failure to implement Enhanced Barrier Precautions (EBP), improper perineal care technique, inadequate disinfection of shared equipment, and lack of required tuberculosis (TB) screening for residents and staff. Several residents with indwelling devices or open wounds did not have EBP signage or personal protective equipment (PPE) available, and staff did not use gowns during high-contact care activities as required by facility policy and CDC/CMS guidance. For example, a resident with a urinary catheter had no EBP order, no EBP signage, and no PPE available; CNAs performed incontinence and catheter care wearing only gloves, then used the same contaminated gloves to apply a clean brief, adjust bedding, and touch privacy curtains. Another resident with left leg wounds requiring dressing changes had saturated dressings and ongoing wound care performed by an LPN and the ADON without gowns, and without EBP signage or PPE supplies in or outside the room, despite the ADON acknowledging the resident was on EBP and that gowns were not available in the facility.

Additional residents with indwelling urinary catheters and nephrostomy tubes also lacked EBP implementation. One cognitively intact resident with an indwelling catheter had no EBP orders and no EBP signage; a CNA entered the room, donned only gloves, and performed perineal care and catheter manipulation while leaning against the resident, without wearing a gown. Another resident with nephrostomy tubes and daily dressing changes had an EBP order, but repeated observations showed no EBP signage and no PPE at or near the room. A staff member entered, donned gloves, and changed the nephrostomy dressings without an isolation gown. A resident with pressure ulcers and a wound care order also had no EBP signage or PPE available over several days. Staff interviews revealed inconsistent understanding of EBP, with one LPN stating they were not exactly sure which residents required EBP and a CNA reporting that isolation gowns had not been seen for weeks.

Surveyors also observed improper perineal care and hand hygiene practices. For one severely cognitively impaired resident, an LPN removed a soiled brief, cleaned the perineal area, then with the same gloved hands applied a clean brief, assisted the resident to dress, transferred the resident to a wheelchair, and propelled the resident to the dining room, without changing gloves or performing hand hygiene. Another resident with a catheter had perineal care performed without PPE, and catheter care was not completed after stool was cleaned from the rectal area; the CNA later stated they "guessed" they should clean the catheter and genitals. The facility’s own incontinent care policy required hand hygiene, glove changes, and use of clean surfaces of cloths for each wipe, which were not followed in these observations.

The survey further documented failure to disinfect shared equipment and to complete required TB screening. A Hoyer lift was used to transfer one resident from bed to wheelchair and then immediately used to transfer another resident for weighing and back to bed, without any cleaning or sanitizing between residents. Staff, including an LPN, CNA, and the DON, acknowledged that the lift should have been wiped down between residents. Review of medical records for multiple newly admitted residents showed no documentation of two-step TB testing or TB screening, despite facility policy requiring TB screening at or before admission. Similarly, review of employee files for numerous newly hired staff showed no documentation of TB tests or chest x-rays, contrary to the facility’s Employee Tuberculosis Test policy.

Environmental cleaning practices also failed to meet facility policy requiring use of an EPA-registered hospital disinfectant. Housekeeping staff reported that the facility had stopped purchasing the previous disinfectant product and were instead using Medorra Limpreza All Purpose Cleaner Lavender scent for floors, measuring it by eye into mop buckets without clear dilution instructions. The product container lacked an EPA registration number, and checks of EPA resources and the manufacturer’s website did not verify it as an EPA-registered or hospital-grade disinfectant. Housekeepers and other staff described supply limitations and lack of a Housekeeping Director, and the Regional Nurse Consultant confirmed there was no training on how much floor chemical to use, while the Administrator stated he expected housekeeping to use appropriate supplies and know correct chemical amounts.