Failure to Use Required PPE During G-Tube Medication Administration Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a nurse administered medication via a G-tube to a resident on Enhanced Barrier Precautions (EBP) without wearing the required gown, using only gloves during the procedure. The resident was observed lying in bed with a G-tube feeding in progress, and EBP signage was posted in the room. Facility policy and posted signage both specified that staff must wear gloves and gowns during high-contact care activities, such as G-tube medication administration, for residents on EBP. Interviews with the Director of Nursing and the Infection Preventionist confirmed that proper PPE, including both gloves and gown, is required for such procedures to prevent cross contamination. The resident involved had multiple medical conditions, including a gastrostomy, end stage renal disease, and dependence on renal dialysis, and was severely cognitively impaired. Physician orders and the care plan indicated the resident was on EBP due to the presence of indwelling medical devices and wounds. Despite these precautions, the nurse failed to follow the facility's EBP policy during medication administration, resulting in noncompliance with infection prevention and control protocols.