Failure to Follow Enhanced Barrier Precautions Between Residents During Bed Baths
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control procedures, specifically Enhanced Barrier Precautions (EBP), when providing care to a resident with a multidrug-resistant organism (MDRO) and then to another resident. One resident had been admitted with diagnoses including UTI and DM and had an active diagnosis of MDRO per the MDS, with a physician’s order placing the resident on EBP due to an indwelling urinary catheter and MDRO. Facility policy required gown and glove use for high-contact care activities such as bathing, hygiene, and changing linens for residents on EBP, and further required changing gloves and gowns after each resident encounter and performing hand hygiene. Surveyors observed a CNA providing a bed bath to the MDRO-positive resident while wearing a protective gown. After completing the bed bath, the CNA did not remove the gown or perform hand hygiene, but instead only changed gloves and then prepared and proceeded to provide a bed bath to another resident who was dependent on staff for showering/bathing and had diagnoses including infection and inflammatory reaction due to cardiac and vascular devices and endocarditis. During interview, the CNA stated they wore the same gown and only changed gloves between the two residents because they believed the first resident was not on any precautions and that the gown was “just for prevention.” The Infection Prevention Nurse later confirmed that the first resident was on EBP for a history of MDRO in the urine and that EBP was intended to protect that resident and others from acquiring MDRO, consistent with the facility’s written policies.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.