Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling medical devices and wounds. For one resident with a stage 2 pressure ulcer not present on admission, staff were observed performing transfers and wound care without donning gowns, despite completing hand hygiene and glove use. Both the RN/ADON and DON provided conflicting statements regarding the necessity of EBP for this resident, with the DON stating EBP should be used for residents with draining wounds or external devices, but ultimately EBP was not applied during care. Another resident with a Foley catheter and a feeding tube, who was totally dependent on staff for care, also did not receive EBP during high-contact activities. During a procedure involving the disconnection and flushing of the feeding tube, the RN failed to wear gloves or a gown, and interacted directly with the resident. Facility policy required EBP for residents with wounds or indwelling medical devices, regardless of known infection or colonization with multidrug-resistant organisms, but this was not followed during the observed care activities.