Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Surveyors identified that the facility failed to implement Enhanced Barrier Precautions (EBP) as required for residents with wounds or indwelling medical devices. Specifically, two residents were observed during care activities where staff did not don gowns, despite clear signage and availability of personal protective equipment (PPE) at the room entrances. In both cases, staff only wore gloves and omitted the gown, resulting in direct contact between their uniforms and the residents during high-contact care activities. One resident with osteomyelitis, a chronic foot ulcer, diabetes, and a Med Port for intravenous antibiotics was observed receiving IV medication from an LPN who wore gloves but not a gown. The LPN's uniform came into direct contact with the resident during the procedure. The resident's care plan did not include EBP interventions, although physician orders specified EBP use. The LPN later confirmed awareness of the EBP requirement but admitted to not following it during the observed care. Another resident with an indwelling urinary catheter due to neurogenic bladder, as well as other chronic conditions, was assisted by a CNA with toileting and catheter care. The CNA wore gloves but not a gown, resulting in direct contact with the resident. The CNA was unsure of the EBP requirements despite prior training and signage. The resident's care plan also lacked EBP interventions, though physician orders required EBP. The DON confirmed that staff had ongoing issues remembering to use EBP, despite reminders and available PPE.