Failure to Post Precaution Signage and Provide PPE for Residents Requiring Enhanced Barrier and Contact Precautions
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program by not ensuring that required Enhanced Barrier Precautions (EBP) and contact precautions were visibly posted and supported with readily available PPE for certain residents. One resident with focal traumatic brain injury, zoster (shingles), and an elevated white blood cell count had a physician order dated 01/13/26 for contact precautions due to an active shingles infection described as highly transmissible and acquired by physical contact. On 01/28/26 at 1:49 pm, observation of this resident’s room showed there was no sign on the door indicating contact precautions and no PPE readily accessible outside the room, despite the active order. Another resident with multiple diagnoses including hypertension, kidney failure, type 2 diabetes mellitus, cellulitis of the right lower limb, and metabolic encephalopathy had multiple wound care orders dated 01/23/26 for unstageable pressure injuries and other wounds to the left hip, right and left ischium, both heels, sacrum, and right big toe. During a random observation of this resident’s room on 01/28/25 at 1:29 pm, there was no EBP sign posted. In a subsequent interview on 01/30/26 at 11:28 am, a CNA confirmed that this resident did not have an EBP sign posted, demonstrating that the facility did not consistently implement its infection prevention and control measures for residents requiring enhanced precautions.
