Failure to Implement Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP), hand hygiene, peri-care practices, medication administration, nebulizer cleaning, and handling of clean clothing. Surveyors observed that a resident with EBP signage requiring gown and glove use for direct care, including catheter and wound care, was assisted back to bed by multiple staff who only donned gloves and did not wear gowns as required. During this care, one aide emptied the resident’s urinary catheter without a gown, another aide placed gloved hands in pockets, and one aide removed gloves and handled linens and exited the room without performing hand hygiene. Later, wound care consultants and an administrative nurse provided wound care to the same resident’s coccyx and lower extremity wounds without wearing gowns, despite the posted EBP requirements and the presence of open wounds. Additional observations showed repeated failures in hand hygiene and aseptic technique during medication administration and personal care. A licensed nurse adjusted a resident’s feet on wheelchair pedals, then applied gloves without prior hand hygiene, checked blood sugar, administered insulin, and handled the medication cart and keys after glove removal without sanitizing hands. For another resident, the same nurse found a nebulizer mask and chamber lying directly on a nightstand with unidentified liquid remaining from a prior treatment; she added new medication to the chamber without disassembling, rinsing, or air-drying the equipment as required by facility policy, and only performed hand hygiene after removing gloves worn throughout the process. The nurse acknowledged the nebulizer should have been rinsed and stored properly. Surveyors also observed improper glove use and lack of hand hygiene during peri-care and wound care, as well as improper handling of clean clothing. Two staff members provided peri-care to a resident, opening a wet brief, cleansing the peri-area and buttocks, then using the same contaminated gloves to open a drawer, retrieve powder, and apply it to the resident’s groin before applying a clean brief and transferring the resident without performing hand hygiene after glove removal. In another case, a nurse performing wound care on a resident’s feet donned gloves and a gown but used the same gloves to move the wheelchair, reposition the resident, open wound supplies, remove soiled dressings, cleanse wounds, apply ointment, and place dressings without changing gloves or performing hand hygiene between dirty and clean tasks. Housekeeping staff were seen carrying a resident’s clean personal clothing on hangers, uncovered, through the hallway. Facility policies in place required EBP with gowns and gloves for high-contact care, specific hand hygiene indications, and detailed nebulizer cleaning and drying procedures, which were not followed in these instances.
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