Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) protocols for two residents requiring additional infection control measures. For one resident with dysphagia and a pressure ulcer, an LPN administered medication via a nasogastric tube after performing hand hygiene and donning gloves, but did not wear a gown as required by EBP. The LPN later stated uncertainty about the need for a gown during this procedure. For another resident with diverticulosis, neuromuscular bladder dysfunction, a urinary tract infection, an indwelling urinary catheter, and an ostomy, staff did not don a gown during catheter and colostomy care, despite the resident being on EBP per physician order and care plan. Observations and interviews confirmed that gloves were used, but gowns were not, during high-contact care activities. Facility policy required both gown and glove use for such activities under EBP, but this was not consistently followed by staff.