Failure to Notify Receiving Provider of Influenza Status and Improper Use of Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not appropriately notifying an outside provider of a resident’s infectious status and not following enhanced barrier precautions during wound care. One resident with prostate cancer, neuromuscular bladder, moderate cognitive impairment, and a documented positive nasal swab for Influenza A was placed on droplet precautions per facility orders. Despite this, the resident was sent unaccompanied to a Veterans Affairs (VA) appointment while still on droplet isolation, with no advance verbal notice to VA staff that he had tested positive for Influenza A. VA staff reported that they were not informed of the resident’s flu status until after the appointment, and facility leadership confirmed that it was not their process to call report before sending residents out and that the resident was sent with paper orders only. The facility’s droplet isolation policy required limiting unnecessary transport of residents on droplet precautions and using masks during essential transport, but there was no documentation of the appointment in the facility record and no evidence that the VA was notified in advance of the resident’s isolation status. A second deficiency involved the facility’s failure to follow its own enhanced barrier precautions (EBP) policy during wound care for a resident with prostate cancer, cerebral palsy, and two stage four pressure sores present on admission that had improved and had no documented current infection. The resident had EBP ordered, and a sign on the door instructed staff to wear a gown and gloves for high-contact activities, including wound care. During an observed wound care procedure, an LPN performed the entire dressing change, including removal of old dressings, wound cleansing, and application of new dressings, without wearing a gown. The LPN confirmed this practice during interview. The facility’s EBP policy required the use of gowns and gloves during high-contact care activities for residents under EBP, including wound care for pressure sores, but this was not followed during the observed procedure.
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