Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for two residents who were under Transmission Based Precautions. According to the facility's policy, EBP involves the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices. For one resident with a non-pressure wound on the left anterior leg, a registered nurse performed wound care by washing hands and wearing gloves but did not don a gown, despite a posted EBP sign and physician orders indicating EBP should be used. The nurse later confirmed that a gown was not worn during the procedure. Similarly, another resident with a gastrostomy tube had a posted EBP sign and physician orders for EBP. The same registered nurse performed gastrostomy tube care, including site care and flushing the tube, using hand hygiene but without donning a gown. The nurse acknowledged that EBP was required and confirmed that a gown was not used during the care. These actions were observed and verified during the survey, demonstrating non-compliance with the facility's EBP policy.