Failure to Implement Contact Precautions for Resident on Transmission-Based Precautions
Penalty
Summary
Two nurse aides failed to implement required Transmission-Based Precautions (TBP) while providing incontinence care to a resident with a physician order for contact precautions due to Enterobacter cloacae complex in her urine. During the observed care, both aides wore only gloves and did not use gowns, despite the facility's policy requiring both gloves and gowns for interactions involving contact with the resident or their environment under contact precautions. The signage on the resident's door indicated Enhanced Barrier Precautions (EBP) rather than the specific contact precautions required by the physician order. Interviews with the nurse aides revealed they were unaware the resident was on TBP, and the Director of Nursing confirmed that appropriate signage indicating the need for gown and gloves was not posted. The Assistant Director of Nursing acknowledged that he did not add a contact precaution sign because an EBP sign was already present for the roommate, not realizing this would not communicate the specific requirements for the resident in question. The administrator also confirmed that a contact precaution sign should have been posted per the physician order.