Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement Enhanced Barrier Precautions (EBP) during direct care for a resident with multiple risk factors for infection. According to the facility's policy, EBP, including the use of gown and gloves, is required during high-contact care activities for residents with wounds, indwelling devices, or known colonization or infection with multi-drug-resistant organisms (MDROs). One resident had a colostomy, a pressure ulcer on the right buttock, and an indwelling urinary catheter, all of which necessitated EBP as documented in the care plan and physician orders. During observation, a CNA was seen emptying stool from the resident's colostomy bag while wearing gloves but not a gown, despite a posted EBP sign on the resident's door. The CNA later acknowledged forgetting to wear a gown, and the facility's Infection Preventionist confirmed that a gown should have been worn during this care activity. This lapse in following established infection control protocols constituted a failure to implement the facility's EBP policy.