Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy during high-contact care activities for residents with tracheostomies. According to the facility's policy, EBP requires the use of both gowns and gloves for residents with indwelling medical devices, such as tracheostomies, during activities like transfers and hygiene care. However, observations revealed that staff did not consistently adhere to these requirements. In one instance, a nurse performed tracheostomy care for a resident without wearing a gown, despite EBP signage and the availability of gowns outside the resident's room. The nurse performed hand hygiene and donned gloves but omitted the gown. She later acknowledged forgetting to wear the gown, even though she had previously received education on EBP and typically followed the protocol. In another case, two nurses provided skin care and assisted with a transfer for a resident with a tracheostomy, again without wearing gowns. Both nurses wore gloves and performed hand hygiene, but neither donned a gown, even though PPE supplies were available and EBP signage was present. One nurse stated she did not usually wear a gown for this resident, citing the resident's discomfort, while the other admitted to not thinking about it at the time. The Director of Nursing confirmed that all staff had been educated on the EBP policy and that the observed actions did not align with facility protocols.