Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and hand hygiene. Facility policy, consistent with CDC guidance, required targeted gown and glove use during high-contact resident care activities for residents with MDROs, wounds, or indwelling medical devices, and required staff to follow IPCP standards including hand hygiene and appropriate PPE use. Despite posted EBP signage and availability of PPE, staff did not consistently don required gowns or perform appropriate hand hygiene during resident care. For one resident with MDRO in the urine and an EBP sign posted outside the room, two CNAs entered to provide incontinence and perineal care without donning gowns, using only gloves as PPE. One CNA later confirmed she provided incontinence and perineal care using only gloves. These actions occurred despite the presence of an EBP sign and a bin of isolation gowns outside the room, and despite facility policy requiring gown and glove use for high-contact care activities under EBP. For another resident on EBP with a posted sign specifying that gloves and a gown must be worn for activities such as wound care, incontinence care, and linen changes, an LPN and a CNA performed coccyx wound care, incontinence care, and a linen change without wearing gowns. The LPN removed a soiled wound dressing and prepared a new dressing without changing gloves between tasks, contrary to hand hygiene expectations. Both staff acknowledged the importance of hand hygiene and PPE but reported not having received education or training on EBP requirements. In a third case, an RN provided tube feeding to a resident with a feeding tube while wearing gloves and a mask but no gown, and initially stated the resident was not on EBP. The IP later stated she had only just become aware of the resident’s feeding tube and had not yet entered EBP orders, despite the process requiring EBP determination at admission for residents with indwelling devices. These observations across three units demonstrate failures to ensure appropriate PPE use for residents on or meeting criteria for EBP and failures in hand hygiene practices during wound care, in direct conflict with CDC guidance and the facility’s own IPCP policy.
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