Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection control procedures while providing care to a resident who was on enhanced barrier precautions (EBP) due to the presence of a feeding tube and tracheostomy. The CNA was observed via audio/video footage wearing gloves and a mask, but not a gown, as required by EBP protocols. During incontinence care, the CNA cleansed the resident from back to front, which could potentially contaminate the urethra with fecal bacteria. The CNA then repositioned the resident without removing the soiled gloves or performing hand hygiene. The resident involved had significant medical needs, including acute and chronic respiratory failure, ventilator dependence, dysphagia, and hemiplegia, and was dependent on staff for all activities of daily living. The Director of Nursing (DON) confirmed the observed failures in infection control practices and acknowledged the absence of a facility-specific EBP policy, despite following CDC guidelines. The incident was identified during a review of the resident's care and confirmed through interviews and video evidence.