Failure to Implement Enhanced Barrier Precautions and Provide Adequate Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement Enhanced Barrier Precautions (EBP) and basic infection prevention measures as required by its own policies and national standards. One resident with multiple risk factors, including type 2 diabetes with neuropathy, chronic venous insufficiency, cognitive impairment, and active non-pressure skin lesions, had a physician order dated 01/20/26 for EBP during high-contact care activities. The resident’s MDS showed cognitive impairment and a need for extensive assistance with activities of daily living, including toileting hygiene and transfers, requiring frequent hands-on care. Despite these factors and the active EBP order, surveyor observations at three separate times on 01/22/26 found no signage or visual indicators posted at the room entrance to alert staff to the need for gown and gloves during high-contact care. Staff were observed entering and exiting the room without any visual cues regarding EBP. The DON confirmed the resident should have been on EBP and that signage should have been posted, acknowledging it was not present, contrary to the facility’s Infection Prevention and Control / Enhanced Barrier Precautions policy revised 03/26/24, which requires clear visual indicators at the room entrance for residents on EBP. A second deficiency involved the facility’s failure to ensure appropriate assistance with incontinence care for another resident with dementia, CVA, abnormal gait and mobility, muscle weakness, lack of coordination, and a need for assistance with personal care. The resident’s MDS documented severely impaired cognitive decision-making, frequent bowel and bladder incontinence, and a need for clean-up assistance with toileting hygiene. The resident’s care plan, last updated 01/14/26, included an ADL self-care deficit related to cognitive impairment, CVA, and dementia, with interventions to allow the resident to toilet independently and offer help as needed. On 01/21/26, the surveyor observed this resident in a common area with brown splatter marks on their shoes, which an LPN confirmed was stool and then cleaned. The LPN stated that all residents were expected to remain clean and that staff were to assist with incontinence care as needed. This situation occurred despite the facility’s incontinence policy, last revised 10/26/23, which states that all incontinent residents will receive appropriate treatment and services based on their comprehensive assessment.
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