Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for one resident. The resident was an elderly female with severe cognitive impairment, admitted with diagnoses including unspecified dementia, hypertension, and major depressive disorder. Her admission MDS documented dependence on staff for all major mobility and transfer activities, and she was coded as having an unstageable pressure injury upon admission. Her care plan, revised in March, identified multiple skin issues, including left and right heel deep tissue injuries (DTIs), a sacral pressure wound, a bruise/discoloration/open blister to the right knee, a left heel ulcer pressure injury, and a right bunion DTI. Based on these wounds, the resident was care planned for EBP, requiring staff to use gown and gloves during high-contact resident care activities. Physician orders for the resident specified Enhanced Barrier Precautions every shift, stating that staff must use gowns and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. The facility’s EBP policy, revised in March, required targeted gown and glove use in addition to standard precautions during high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care. The policy further stated that EBPs are indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization status. EBP signage was posted outside the resident’s room to indicate the need for PPE. During an observation, the surveyor approached the resident’s room while the door was open and the curtain drawn, and CNA J stepped out, stating she was performing resident care. CNA J was observed wearing black scrubs without a gown, despite EBP signage outside the room, and had just completed incontinent care for the resident. In a subsequent interview, CNA J acknowledged that the signage indicated PPE was needed when providing care but stated she was unsure whether it applied to the resident or her roommate and reported she had never worn PPE when providing care to this resident, only to the roommate. She was unsure whether the resident had wounds and stated that the risk of not wearing PPE was infection. In contrast, LVN K, assigned to the hall, stated that PPE was required when providing direct care to the resident because she had wounds and noted that CNAs had access to the resident’s plan of care in the electronic health record and to room signage indicating PPE requirements. The DON stated her expectation was that PPE be worn when residents require it and identified infection as the risk when it is not used.
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