F0880

D

Failure to Follow Enhanced Barrier Precautions and TB Screening Protocols

Burgaw, North Carolina Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care of a resident with complex medical needs. The resident had a tracheostomy, a gastrostomy tube, and a Stage IV sacral pressure ulcer, and an EBP sign was posted on the room door with a PPE supply bag containing gloves and gowns. During an observation, two nurse aides provided incontinence care to this resident while wearing gloves but did not don gowns, despite the EBP requirements for targeted gown and glove use during high-contact resident care activities. Both aides reported they did not know they were required to wear gowns when providing care to this resident and expressed confusion about PPE use and the purpose of EBP, even though they stated they had received infection control training.

The Infection Control Preventionist Nurse confirmed that staff had received infection control training on EBP and were required to complete monthly infection control in-services through an online platform. She stated that the two nurse aides should have worn gowns along with gloves when providing direct care to the resident on EBP. The DON also stated that staff received infection control training and were expected to follow infection control guidelines and wear PPE when providing direct care to residents on EBP. These statements confirmed that the observed care did not comply with the facility’s written EBP policy and expectations for PPE use.

Surveyors also found that the facility failed to follow its Tuberculosis (TB) Control Plan for a newly admitted resident. The policy required all first-time residents to receive a two-step tuberculin skin test (TST) on admission, with Step 2 administered 1–3 weeks after Step 1 if the initial reaction was less than 10 mm. The resident received Step 1 with a negative result of 0.1 mm, but Step 2 was not administered within the required 1–3 week timeframe and instead was given several months later. The Infection Control Preventionist Nurse reported that the Medication Administration Record showed the resident refused Step 2 on one date, but acknowledged that staff should have re-offered the test within the required timeframe and that this did not occur. The resident, who was cognitively intact, did not recall refusing the test and stated she would have agreed to complete Step 2 if it had been offered again. The Nurse Practitioner and DON both indicated that the two-step TST guidelines called for Step 2 to be given within 1–3 weeks after Step 1, confirming that the facility did not follow its TB screening policy for this resident.