Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not following Enhanced Barrier Precautions for a resident with a history of sepsis, MRSA, and Clostridium difficile. During an observation, two CNAs entered the resident's room, which had an Enhanced Barrier Precautions sign posted and personal protective equipment available outside, to perform incontinent care. The CNAs washed their hands and donned gloves but did not wear gowns as required. There were no gowns in the room at the time. Both CNAs later acknowledged they should have worn gowns and attributed their oversight to being in a hurry and unfamiliarity with the resident, as well as not recalling their last in-service on enhanced barrier precautions. The DON confirmed that the expectation was for staff to wear gowns when providing direct care to residents on Enhanced Barrier Precautions and stated that staff had been previously in-serviced on this protocol. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with multi-drug resistant organisms or certain medical conditions. The failure to follow these procedures was observed and confirmed through staff interviews and record review.