F0880

E

Failure to Implement Enhanced Barrier Precautions, PPE Use, and Hand Hygiene

Belleville, Illinois Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly implement its infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), use of PPE, and hand hygiene. Multiple residents with indwelling devices or acute infectious symptoms were not consistently identified for EBP or isolation, and required signage and PPE were often missing or not used. For one cognitively intact resident with a PICC line receiving daily IV antibiotics for a left foot wound, there was no EBP sign or PPE outside the room, and the physician orders only listed Standard Precautions, despite the care plan documenting EBP due to high MDRO risk and requiring staff to wear gown and gloves during high-contact care.

Another resident with osteomyelitis of the vertebra, a PICC line, and a JP drain had physician orders for EBP related to MDRO risk and was receiving IV and oral antibiotics for a spinal abscess. An EBP sign and PPE cart were present, and the resident reported staff usually wore masks and gloves but did not don gowns when providing care. This resident was later placed in a shared room with a newly admitted roommate who had a frequent cough and, by physician note, a fever of 101.1°F, lethargy, and new cough without sputum production. The roommate’s door had EBP signage and a PPE cart, and the infection preventionist stated the roommate was being placed on both contact and droplet isolation for an unknown illness per policy, but staff were observed entering and exiting the room without PPE.

A cognitively intact resident with multiple chronic conditions, including chronic respiratory failure and dependence on supplemental O2, was observed on oxygen and later with IV fluids running wide open, a portable suction unit at bedside, and coughing up sputum. The respiratory therapist assisted with sputum without any PPE, and there was no EBP or isolation signage or PPE outside the room, even though nursing staff reported the resident had become lethargic, developed a fever, and was coughing up brown sputum, with COVID testing negative and further tests pending. A subsequent physician order documented contact and droplet isolation for fever of unknown origin, but at the time of observations there was still no signage or PPE available.

Another cognitively intact resident with a G-tube had a physician order for EBP due to MDRO risk related to the G-tube. During observation, an LPN turned off the tube feeding, disconnected the feeding line from the G-tube, and plugged the tube without donning any PPE, and there was no PPE at the room entrance. Staff interviews, including the infection preventionist, LPNs, and the DON, confirmed that residents with G-tubes, PICC lines, drains, or other indwelling devices should be on EBP, with staff wearing gown and gloves (and mask as indicated), and that residents with fever and cough should be placed on contact and droplet precautions with appropriate signage and PPE.

The deficiency also includes failures in hand hygiene during medication administration. One resident with a PICC line receiving IV daptomycin via the PICC was observed when an RN entered the room and administered the IV medication without performing hand hygiene before donning gloves. In another case, an LPN administered medications to a different resident without completing hand hygiene prior to gloving after entering the room. These practices were inconsistent with the facility’s Infection Control – Standard and Transmission-Based Precautions policy, which states that hand hygiene is the single most effective means of preventing infections and must be performed before passing medications and when each resident’s care is completed, and with the facility’s EBP policy requiring clear signage and readily available PPE for residents on EBP.