Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves, for residents with conditions requiring such measures. Specifically, one resident with a Foley catheter, another receiving tube feedings and wound care, and a third with an ostomy did not have EBP signage or personal protective equipment (PPE) available or in use. Observations revealed that no EBP signage or PPE was present outside any of the residents' rooms, and staff did not use gowns or gloves when providing care to these residents. Interviews with the affected residents confirmed that staff did not use appropriate protective equipment during care activities. Staff interviews indicated a lack of consistent EBP implementation, with some staff acknowledging that EBP should be used for residents with indwelling devices or wounds, but admitting that these precautions had not been followed. The facility's policy required EBP for residents with wounds or indwelling medical devices, and mandated that gowns and gloves be made available near or outside the resident's room. Despite this, staff reported that EBP had not been practiced, and attributed the lapse to staff oversight and recent changes in nursing leadership.