Failure to Implement Enhanced Barrier Precautions and Basic Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow Enhanced Barrier Precautions (EBP) and basic infection prevention practices for multiple residents. Surveyors observed that staff did not consistently use required PPE, including gowns and gloves, when providing high-contact care to residents on EBP or with open wounds and indwelling devices. For one resident with an indwelling catheter, CNAs used a sit-to-stand mechanical lift that had not been sanitized between residents, did not wear gowns as required for EBP, and allowed the resident’s urine drainage bag and tubing to rest on and drag along the floor during transfers. One CNA removed gloves and exited the room without performing hand hygiene. Staff acknowledged they should have worn gowns and sanitized the lift but stated they were in a hurry. Surveyors also observed improper hand hygiene and handling of ice during an ice pass. A CNA left the ice scoop in the cooler and the lid open while going in and out of resident rooms, and another CNA repeatedly retrieved resident cups from rooms, filled them from the cooler, and returned them without performing hand hygiene between residents. Both CNAs later confirmed that the scoop should be kept in a holder, the cooler lid should remain closed when not in use, and that hand hygiene should be performed between residents. A licensed nurse confirmed that facility expectations were for the ice coolers to remain closed, the scoop to be stored in a holder, and staff to wash their hands between residents. Additional deficiencies were identified related to EBP implementation and wound management. One resident with EBP signage on the door had PPE available, and a CNA initially used gown and gloves with appropriate hand hygiene during incontinence care, but when two CNAs later returned to transfer the resident with a mechanical lift, they did not wear gowns despite acknowledging the resident was on EBP. Another resident with multiple open and scabbed wounds, bleeding onto clothing and linens, and a widespread rash had no EBP signage or PPE setup at the door, and the electronic medical record lacked a detailed skin assessment despite the presence of at least 13 documented wounds. Facility policy required all skin lesions to be covered with dry dressings and mandated hand hygiene, but staff confirmed that EBP had not been implemented for this resident and that open, bleeding wounds had been present for a couple of months.
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