Failure to Follow Enhanced Barrier Precautions During High-Risk Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care activities for residents with indwelling devices. Specifically, two nurses were observed providing tracheostomy care, including suctioning, and administering tube feedings to residents without donning the required protective gown, despite wearing gloves and masks. Facility policy and posted signage clearly indicated that gowns and gloves were required for high-contact care activities involving residents with tracheostomies and gastrostomy tubes. Both nurses performed these procedures without a gown, and one nurse stated she was unaware of the requirement, while the other acknowledged the omission as an error. Observations confirmed that EBP signage and PPE supplies were present outside the residents' rooms, and interviews with the Infection Control Preventionist and Director of Nursing confirmed that staff had received education on EBP and PPE use. The residents involved had tracheostomies and gastrostomy tubes, placing them at higher risk for transmission of multi-drug-resistant organisms, which the EBP policy was designed to address. The failure to follow established infection control protocols was directly observed during care activities for these residents.