Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for a resident with multiple complex medical conditions, including Parkinsonism, pulmonary hypertension, protein-calorie malnutrition, acute respiratory failure, rheumatic mitral valve disease, a stage 4 pressure ulcer, a history of prostate cancer, dysphagia, and muscle weakness. The resident had a physician's order for EBP due to these risk factors. A sign was posted outside the resident's room instructing staff to wear gloves and gowns for high-contact care activities, such as dressing, bathing, transferring, changing linens, providing hygiene, toileting assistance, device care, and wound care. Despite these instructions, two rehabilitation staff members entered the resident's room to assist with repositioning without donning the required personal protective equipment (PPE). Both staff members acknowledged during interview that they did not follow the EBP protocol and should have worn PPE before providing care. Review of the facility's policy confirmed that EBP is indicated for residents with chronic wounds and other risk factors, in accordance with CDC guidelines.