Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) and standard precautions to prevent the spread of infections for three residents with wounds and/or indwelling medical devices. For one resident with a recent surgical procedure and a groin incision, a registered nurse performed wound care without donning a gown, despite signage and care plan instructions requiring both gloves and a gown for such procedures. The nurse stated she considered wearing a gown but decided against it because the wound was not open. Another resident with diabetes, heart disease, wounds, and an indwelling Foley catheter required total assistance for transfers and had a care plan directing staff to use EBP, including gown and gloves, during high-contact care activities. A certified nursing assistant emptied the resident's catheter bag wearing only gloves, failing to use a gown as required by the care plan and posted signage. The staff member later acknowledged awareness of the EBP signage but did not follow the protocol. A third resident with cognitive abilities, a stage three inter-gluteal pressure ulcer, and an indwelling urinary catheter required extensive assistance and use of a mechanical lift. During care involving transfer, incontinence care, and wound cleansing, three staff members wore gloves but did not don gowns, contrary to the care plan and facility policy. Additionally, wash cloths used for wound care were placed directly on the bed sheet without a barrier, and a graduated cylinder used for emptying the Foley bag was placed on the bed frame without a barrier. The facility's policy clearly required gowns and gloves for high-contact care activities involving wounds and indwelling devices.