Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention practices by not adhering to enhanced barrier precautions (EBP) for two residents. For one resident with a history of a pressure ulcer, seizure disorder, and osteoporosis, the care plan did not mention EBP, and during an observed treatment of a left heel pressure ulcer, the registered nurse did not apply EBP prior to the procedure. The resident confirmed that staff had only recently started using gloves and gowns, and the nurse admitted to forgetting to wear the required EBP during the treatment. The co-director of nursing stated that the expectation is for staff to wear EBP when providing care or treatments. For another resident with a history of stroke, hemiplegia, and a G-tube, the care plan documented the need for EBP. However, during an observed medication administration via G-tube, two staff members sanitized their hands and applied gloves but did not wear gowns as required. One staff member acknowledged knowing the protocol but stated she forgot to wear the gown. The director of compliance confirmed that the expectation is to wear both gown and gloves for EBP during such procedures.