PHILADELPHIA, PA - State inspectors found that Care Pavilion Nursing and Rehabilitation Center failed to properly implement infection prevention protocols, potentially exposing vulnerable residents to serious health risks during a February inspection.
Breakdown in Enhanced Barrier Precautions
The most significant violation occurred when nursing staff failed to follow Enhanced Barrier Precautions for a resident requiring specialized infection control measures. On February 18, 2025, inspectors observed a licensed nurse cleaning a resident's feeding tube site without wearing required personal protective equipment (PPE), despite the resident being under doctor's orders for enhanced protection protocols.
The resident had been placed on Enhanced Barrier Precautions on February 12, 2025, with specific physician orders requiring gown and gloves during all high-contact care activities. These precautions were implemented due to the resident's feeding tube and chronic wound condition, both of which create elevated infection risks.
When inspectors witnessed the violation at 11:39 a.m., they immediately confirmed the oversight with the licensed nurse involved, who acknowledged not following the required safety protocols.
Medical Significance of Enhanced Barrier Precautions
Enhanced Barrier Precautions represent a critical line of defense against multi-drug-resistant organisms and novel pathogens in healthcare settings. These protocols are specifically designed to prevent the transmission of dangerous bacteria and infections that can be life-threatening for nursing home residents with compromised immune systems.
Residents with feeding tubes face particular vulnerability to infections. The tube site creates a direct pathway for bacteria to enter the body, while chronic wounds provide additional entry points for harmful microorganisms. Without proper protective barriers, healthcare workers can inadvertently transfer pathogens between residents or introduce new infections to vulnerable individuals.
The failure to wear required PPE during high-contact activities like tube site cleaning represents a fundamental breach of infection control standards. Such oversights can lead to serious complications including sepsis, pneumonia, and other potentially fatal infections in elderly residents who may already be medically fragile.
Industry Standards and Proper Protocol
According to established healthcare protocols, Enhanced Barrier Precautions require strict adherence to protective equipment guidelines during all designated high-contact activities. These measures go beyond standard precautions and are implemented when residents face elevated infection risks due to medical devices, wounds, or previous exposure to resistant organisms.
Proper implementation should include comprehensive staff training on when and how to use protective equipment, clear posting of precaution requirements in resident rooms, and regular monitoring to ensure compliance. Healthcare facilities are expected to maintain systematic oversight of infection control protocols, particularly for residents requiring enhanced protection measures.
The Pennsylvania Department of Health regulations specifically require nursing facilities to maintain effective infection prevention and control programs, with particular attention to residents who may be at higher risk for healthcare-associated infections.
Facility Response and Compliance Requirements
Care Pavilion Nursing and Rehabilitation Center must develop and implement a comprehensive plan of correction to address the infection control deficiencies identified during the inspection. This typically includes retraining nursing staff on proper PPE protocols, implementing enhanced monitoring systems, and establishing quality assurance measures to prevent future violations.
The facility received citations under multiple Pennsylvania health regulations, including requirements for resident care policies and nursing services standards. Inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents during the review period.
Additional Issues Identified
The inspection also revealed deficiencies in the facility's overall infection prevention and control program implementation. Inspectors found gaps in the systematic approach to maintaining Enhanced Barrier Precautions, suggesting the need for more comprehensive staff education and oversight procedures.
The violations underscore the importance of consistent adherence to infection control protocols in nursing home environments, where residents often have multiple risk factors that make them particularly susceptible to healthcare-associated infections. Proper implementation of Enhanced Barrier Precautions serves as a crucial safeguard for protecting resident health and preventing the spread of dangerous pathogens within the facility.
State regulators will continue monitoring the facility's progress in addressing these infection control deficiencies and ensuring full compliance with established safety protocols designed to protect nursing home residents from preventable healthcare-associated infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care Pavilion Nursing and Rehabilitation Center from 2025-02-18 including all violations, facility responses, and corrective action plans.
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