Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP). Specifically, staff did not consistently use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with chronic wounds, pressure ulcers, and surgical wounds. Observations included a Licensed Practical Nurse performing a dressing change for a resident with an unstageable pressure ulcer without donning a gown, despite the resident being on EBP due to the presence of a chronic wound. Further observations revealed that two staff members transferred a resident with pressure and surgical wounds without wearing gowns, as required by EBP protocols. After completing the transfer, one staff member failed to perform hand hygiene before proceeding to care for another resident with a surgical wound and wound vacuum, also on EBP. During this subsequent care, staff again did not don gowns as required, although gloves were used and hand hygiene was performed at certain points. The facility's policies, reviewed by surveyors, clearly stated that gowns and gloves must be worn during high-contact care activities for residents on EBP, and that hand hygiene should be performed before and after resident contact, as well as when moving between contaminated and non-contaminated areas. Interviews with the Director of Nursing and the Administrator confirmed that staff did not follow these protocols during the observed care activities, resulting in a failure to adhere to established infection prevention and control measures.