Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required by its own policy and physician orders for two residents who were identified as needing these precautions. For one resident with a wound and a history of toe amputation, a sign indicating EBP was posted and personal protective equipment (PPE) was available outside the room. However, during a wound care and dressing change, the wound nurse wore gloves but did not don a gown as required by the EBP policy, despite the resident having an open wound and being under an active EBP order. Similarly, another resident with an indwelling urinary catheter had EBP signage and PPE available, and was under a physician's order for EBP due to the catheter. During catheter care, a certified nursing assistant wore gloves but did not wear a gown, contrary to the facility's EBP policy which mandates both gloves and gowns for high-contact care activities. Both staff members acknowledged after the fact that they should have worn gowns while providing care to these residents under EBP.