F0880

E

Failure to Follow Enhanced Barrier Precautions and Standard Infection Control Practices During High-Contact Care

Saint Louis, Missouri Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and standard precautions, during high-contact care for multiple residents. The facility’s EBP policy required an order for EBP for residents with chronic wounds, indwelling medical devices, or infection/colonization with certain MDROs, clear signage on the door indicating required PPE and high-contact activities, and the use of gown and gloves for high-contact care such as dressing, transferring, providing hygiene, changing linens, and changing briefs or assisting with toileting. The standard precautions policy required assuming every person could be infected or colonized and minimally handling contaminated laundry with appropriate PPE, placing it in leak-proof bags at the location of use. Surveyors observed that these policies were not followed for several residents.

One resident with severe cognitive impairment, total dependence for toileting and personal hygiene, and diagnoses including stroke, multiple sclerosis, and altered mental status had an EBP sign and PPE at the room door. A CNA provided incontinence and peri-care without wearing a gown, contrary to the EBP requirement for high-contact care. During this care, the CNA cleaned the resident’s genital area from front to back abdomen (back to front), placed a soiled pad directly on the floor without a barrier, and moved blankets from the resident’s bed to the roommate’s bed and then back to the original resident’s bed. The Assistant DON later stated that peri-care for a female resident should be performed front to back, linens should not be transferred between residents’ beds due to cross contamination, and staff should wear a gown, gloves, and mask as needed for high-contact care.

Another resident, cognitively intact but dependent for toileting and personal hygiene and always incontinent of bladder with frequent bowel incontinence, had a physician order for EBP for a chronic wound, with gown and gloves required for high-contact care. An EBP sign and PPE were present on the door. A CNA entered, performed hand hygiene, donned two pairs of gloves but no gown, and provided incontinence care, including cleaning the groin and between the legs. The CNA placed a soiled blanket on the floor without a barrier, used double gloving, and later used a folded blanket as a substitute for a pad, stating the facility had run out of pads. The CNA then picked up linens from the floor and placed them in a trash bag. The ADON stated staff should not double glove, should remove gloves and perform hand hygiene, and should not place soiled linens on the floor.

A third resident with moderate cognitive impairment, dependence for toileting and personal hygiene, and diagnoses including stroke and hemiplegia/hemiparesis had an order for EBP for a chronic wound with gown and gloves required for high-contact care. This resident preferred to remain in bed and was totally dependent on staff for toileting and used incontinence products. A CNA provided peri-care while wearing gloves but did not wear a gown, despite the EBP order and high-contact nature of the care. A fourth resident, rarely or never understood, totally dependent for toileting and personal hygiene, always incontinent of bladder and bowel, and with diagnoses including cerebral palsy and gastrostomy status, had a care plan indicating EBP for a g-tube with gown and gloves required for high-contact care, but there was no corresponding physician order for EBP on the physician order sheet. An EBP sign and PPE were on the door, and a CNA provided peri-care wearing gloves but no gown.

Additional staff interviews confirmed expectations that conflicted with observed practices. One CNA stated that residents requiring EBP were identified by a sign and PPE at the door and that staff should wear a gown, mask, face shield, and gloves every time they entered the room, remove PPE before exiting, avoid double gloving, place soiled linens in a trash bag rather than on the floor or another resident’s bed, and perform peri-care front to back. Another CNA similarly stated that peri-care should be front to back, staff should not double glove, and soiled linens should be placed in a linen cart or trash bag, and that staff should wear gown, gloves, and mask when providing close contact care to residents. The Administrator stated she expected staff to follow the facility’s infection control policies and procedures. These statements contrasted with the observed failures to use gowns during EBP-required high-contact care, improper handling of soiled linens, improper peri-care technique, and inconsistent implementation of EBP orders and signage.