A resident with peripheral vascular disease, muscle weakness, CHF, and an active wound infection was on Enhanced Barrier Precautions (EBP) with posted signage requiring PPE use for direct care. Facility policy required targeted gown and glove use to prevent transmission of multidrug-resistant organisms. Despite this, a CNA was observed providing direct care to the resident without any PPE and later acknowledged that PPE should have been worn, while the DON stated the expectation that all staff follow EBP guidelines.
A resident with sepsis, morbid obesity, an abdominal wound vac, an unstageable sacral pressure ulcer, and an actual infection with a surgical wound did not have required Enhanced Barrier Precautions (EBP) signage posted in the room, and PPE was not readily accessible. During observed wound care, an LPN performed treatment without donning a gown. In interviews, the LPN reported believing gowns were only required for residents on transmission-based precautions, and the IP stated that EBP was only needed for residents with infected wounds, demonstrating a failure to implement EBP and appropriate PPE use during high-contact wound care activities.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Surveyors identified failures in infection prevention and control when a CNA exited a room wearing a gown and gloves instead of doffing PPE before leaving, contrary to the IPC’s stated expectations. In a separate case, a resident admitted with C. diff and a Foley catheter had no EBP signage or PPE available near the room, despite an LVN acknowledging that EBP should have been in place for this resident.
A resident with a G-tube, indwelling catheter, unhealed pressure ulcers, and ongoing wound care orders required Enhanced Barrier Precautions (EBP), but staff failed to post EBP signage at the room entrance during multiple observations. The resident had active orders for enteral feeding, catheter management, and daily wound care. The ADM and DON both acknowledged that the resident met criteria for EBP and that signage is used to inform staff of required precautions, yet no such signage was present, demonstrating a failure to implement the infection prevention and control program.
Surveyors found that a resident with a Foley catheter, care planned for this device, did not have required enhanced barrier precaution signage or PPE (gowns and gloves) available outside the room. During observation, no sign or PPE was present, and in interview the UM confirmed their absence and acknowledged that both were expected for this resident due to the Foley catheter. This deficiency was identified for one of three residents reviewed for Foley catheter-related infection control practices.
A resident on enhanced barrier precautions (EBP) had a tube feeding performed by an LPN who wore gloves but did not don the required gown, despite EBP signage on the room door specifying gown and glove use for high-contact care. During interviews, the LPN initially stated a gown was not required for accessing the feeding tube, then later acknowledged after reviewing the sign that a gown should have been worn. The DON confirmed that tube feedings require appropriate PPE and that the observed practice did not meet expectations.
Surveyors found that the facility failed to consistently implement its infection prevention and control program. A resident on Enhanced Barrier Precautions (EBP) received direct care from two CNAs who did not don required PPE despite EBP signage on the door. In a separate incident, a resident on EBP was transferred with a mechanical lift, and after completing care and removing PPE, CNAs moved the lift directly to another room without cleaning or disinfecting it. The CNAs later acknowledged they had not followed protocol, and the DON, serving as Infection Preventionist, stated that staff are expected to perform hand hygiene, follow infection control precautions, and clean and disinfect all medical equipment after each use.
Surveyors identified that staff failed to follow infection prevention practices for two residents. For a resident receiving wound care for a shin wound and a stage 2 pressure ulcer, staff did not wear gowns during high-contact care despite posted EBP signage and available PPE, and the resident’s body was in direct contact with a CNA’s body during repositioning. For another resident with COPD on 2 LPM oxygen via nasal cannula, staff did not follow orders to change oxygen tubing weekly and label it with the date, leaving the nasal cannula in use without any date marking and with no way to determine when it was last changed.
Surveyors found that the facility did not consistently implement its infection prevention and control program when two residents who required contact or Enhanced Barrier Precautions did not have appropriate precaution signage posted or PPE readily available outside their rooms. One resident with active shingles and an order for contact precautions had no contact precaution sign or accessible PPE at the room entrance. Another resident with multiple pressure injuries and other wounds, with several wound care orders in place, lacked an EBP sign on the room door, a fact later confirmed by a CNA.
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