Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP) during morning care and wound observation. The deficiency was identified through a review of facility protocol, observations, interviews, and clinical records. The facility's policy for EBP, revised in December 2024, is intended to reduce the spread of multi-drug-resistant organisms by employing targeted gown and glove use during high-contact resident care activities. EBP is indicated for residents with wounds and/or indwelling medication devices. Resident R102, who was admitted to the facility with spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia, and a gastrostomy, had orders to use EBP during tube feedings, incontinence care, and wound care. However, on two separate occasions, staff members failed to use EBP while providing care. On March 17, 2025, a nursing assistant provided incontinence care without EBP, and on March 18, 2025, a unit manager provided wound care without EBP. The Assistant Director of Nursing was informed and confirmed the requirement for EBP use during care.
Plan Of Correction
1. Resident R-102 continues with enhanced barrier precautions. Employees E-13 and E-14 have been re-educated on Enhanced Barrier Precautions. 2. All residents who require Enhanced Barrier Precautions will be identified and protective equipment made available for staff with appropriate identification signs to ensure proper use of PPE for residents on Enhanced Barrier Precautions to ensure infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. 3. Nurse Educator/Designee will re-educate staff on the policy, Enhanced Barrier Precautions. 4. The DON/Designee will conduct weekly random audits times 2 months to ensure that staff is utilizing the proper PPE in the rooms of residents identified requiring Enhanced Barrier Precautions. 5. Audit results will be reviewed monthly by QAPI Committee.