The violation occurred during an October 6 inspection at Camp Hill Skilled Nursing and Rehabilitation Center, where federal investigators found staff failed to follow enhanced barrier precautions for a resident with a stage 2 pressure ulcer on her left heel.
Resident 7 lay in bed as Employee 2, a licensed practical nurse, completed the dressing change at 12:30 PM. The nurse wore only gloves despite facility policy requiring a gown for high-contact activities like wound care.
No sign marked the resident's door indicating enhanced barrier precautions were in effect.
The facility's own policy, revised December 6, 2024, requires enhanced barrier precautions for residents with wounds or medical devices who don't meet criteria for full contact precautions. Pressure ulcers are injuries to skin and underlying tissue caused by prolonged pressure.
When questioned immediately after the dressing change, Employee 2 told inspectors that Resident 7 was not on enhanced barrier precautions at that time.
The resident's medical record showed diagnoses including the left heel pressure ulcer and chronic kidney disease. Her care plan, last revised August 20, specifically addressed skin breakdown related to impaired mobility and the stage 2 pressure ulcer.
But no physician's order for enhanced barrier precautions appeared in her current medical orders.
The Director of Nursing acknowledged the failure during an interview at 2:15 PM the same day. She told inspectors that Resident 7 should be on enhanced barrier precautions and promised to ensure the protocols would be initiated moving forward.
Enhanced barrier precautions serve as an intermediate level of infection control between standard precautions and full contact isolation. The protocols help prevent transmission of multidrug-resistant organisms and other infections in nursing home settings where residents often have compromised immune systems.
Stage 2 pressure ulcers involve partial thickness skin loss, extending into the dermis. These wounds create potential entry points for bacteria and require careful infection control measures during treatment.
The inspection was conducted in response to a complaint. Federal investigators reviewed eight residents on transmission-based precautions and found the infection control failure affected one resident.
Camp Hill Skilled Nursing and Rehabilitation Center received a citation for failing to provide and implement an adequate infection prevention and control program. The violation was classified as minimal harm or potential for actual harm.
The facility's infection control policy specifically identifies dressing changes as high-contact activities requiring enhanced protective equipment. Staff performing these procedures should wear both gloves and gowns to prevent contamination and protect against exposure to wound drainage or other potentially infectious materials.
The gap between policy and practice left both the resident and healthcare worker vulnerable. Without proper barrier protection, the nurse risked exposure to infectious materials while potentially introducing contaminants to an open wound.
Pressure ulcers affect approximately 2.5 million Americans annually and contribute to thousands of deaths. Proper wound care requires strict adherence to infection control protocols, particularly in institutional settings where residents may harbor resistant bacteria.
The resident's chronic kidney disease further complicated her infection risk profile. Patients with kidney disease often have weakened immune systems, making them more susceptible to wound infections and slower to heal.
Federal regulations require nursing homes to establish and maintain infection prevention and control programs that include policies for identifying residents who require enhanced precautions and training staff on proper implementation.
The October inspection found that despite having written policies in place, Camp Hill failed to ensure staff understood when enhanced barrier precautions applied and how to implement them correctly.
The Director of Nursing's admission that the resident should have been on enhanced barrier precautions highlighted a breakdown in the facility's infection control oversight. The lack of physician orders for the precautions suggested gaps in communication between nursing staff and medical providers.
No signage on the resident's door meant other staff members entering the room would be unaware of the required precautions, potentially exposing multiple workers and increasing infection transmission risks.
The violation demonstrates how individual lapses in infection control can cascade into broader safety failures, leaving vulnerable residents at risk while staff work without adequate protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Camp Hill Skilled Nursing and Rehabilitation Ctr from 2025-11-20 including all violations, facility responses, and corrective action plans.
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