F0684

D

Failure to Implement Physician-Ordered Enhanced Barrier Precautions

Glendale, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement physician-ordered Enhanced Barrier Precautions (EBP) for a resident with multiple infection risks. The resident was readmitted with diagnoses including a UTI, pneumonia, and sepsis, and had multiple lower pressure injuries, impaired skin integrity, and an indwelling urinary catheter. The resident’s care plan identified risks for infection, catheter-associated UTI, and transmission of MDROs, and included goals and interventions requiring compliance with EBP, including the use of clean gowns and gloves during all high-contact care activities. A physician’s order dated 11/18/2025 directed continuation of EBP for infection control.

Surveyors’ review of records and interviews with staff confirmed that the EBP order and related care plan interventions were not implemented. On review of the resident’s order summary with an LVN, it was confirmed that EBP should have been in place, including posting of an EBP sign and provision of PPE for staff. The LVN stated that implementing physician orders was important so residents and visitors would know what protective equipment to wear to limit infection transmission. The care plan for risk of healthcare-associated infection, dated 11/20/2025, specified that all direct care staff were to demonstrate and document 100% compliance with EBP protocols, but this was not carried out in practice.

Direct observations showed that staff were providing hands-on care without PPE and without any visible indication that EBP was required. A CNA was observed touching the resident’s blanket, repositioning the Foley catheter bag, and assisting the resident without wearing any PPE, and the CNA stated they did not know the resident required PPE under EBP. On a separate observation, there was no EBP signage or PPE available outside the resident’s room. An RN verified that no EBP sign was posted and no PPE was available, despite acknowledging that EBP had been ordered by the physician to decrease infection transmission. The Infection Preventionist also stated that the resident should have been placed on EBP with appropriate PPE available and that the physician’s order should have been implemented. The facility’s infection prevention and control policy required implementation of appropriate enhanced barrier and transmission-based precautions when necessary, consistent with CDC guidelines, but these were not followed for this resident.