Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) protocols during resident care. Specifically, a treatment nurse provided wound care to a resident with peripheral vascular disease, diabetes mellitus, and bilateral lower extremity arterial ulcers without donning the required gown, despite an EBP sign being posted in the room. After completing the wound care, the nurse exited the resident's room carrying soiled PPE on a tray and disposed of it in the hallway, rather than removing and discarding the PPE inside the resident's room as required by policy. The nurse acknowledged both lapses when questioned. Additionally, a certified nursing assistant was observed assisting with an oral assessment for another resident who was on EBP, but did not wear a gown while placing gloved hands in the resident's mouth. The CNA stated she believed a gown was not required for this care activity, despite the EBP sign on the resident's door. The infection preventionist later confirmed that the resident was on EBP and that a gown should have been worn for direct care involving the mouth. These failures were observed to have the potential to affect the facility's entire census of 96 residents.