Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices when staff did not follow enhanced barrier precautions (EBP) for a resident on transmission-based precautions. The resident was admitted in March 2024 with diagnoses including a gastrostomy and stenosis of the larynx. On 3/4/26 at 10:34 a.m., an observation showed a sign outside the resident’s room indicating the resident was on EBP. During this time, CNA 1 and CNA 2 transferred the resident from bed to wheelchair without wearing gowns, despite the posted EBP sign. In subsequent interviews, CNA 1 and CNA 2 confirmed they were not wearing gowns during the transfer. CNA 1 stated she was aware the resident was on EBP and that she should have worn a gown, and CNA 2 stated he should have been wearing a gown because it could spread an infection to other residents. LN 1 confirmed the resident was on EBP and stated CNAs should have been wearing proper PPE to minimize the risk of passing infection to other residents. The Infection Preventionist also confirmed the expectation that staff follow the precaution signs and wear appropriate PPE, including gowns, under EBP. Review of the facility’s infection control policy, dated 1/12/12, indicated the facility’s infection control policies and procedures are intended to help prevent and manage transmission of diseases and infections and that staff are trained on these policies upon hire and periodically thereafter.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.