Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
Facility staff failed to follow established infection control procedures when a nurse did not don a gown while administering a tube feeding to a resident who was under Enhanced Barrier Precautions. The facility's policy required staff to wear both gowns and gloves when performing high-contact care activities, such as tube feedings, for residents with devices like feeding tubes. During an observation, the nurse entered the resident's room, which had signage indicating Enhanced Barrier Precautions, washed her hands, and put on gloves but did not wear a gown before administering the tube feeding. When interviewed, the nurse stated she believed a gown was not necessary for tube feeding administration and was unsure if the precautions applied to the resident or the roommate. The Infection Preventionist confirmed that the precautions were for the resident with the feeding tube and that the nurse had previously been educated on the requirements. Facility leadership clarified that staff should assume precautions apply to both residents in a shared room if there is any uncertainty, and that proper PPE should be used as indicated by signage and posted lists.