Failure to Implement Enhanced Barrier Precautions According to Policy
Penalty
Summary
Surveyors identified that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policy for two residents who were on EBP. Observations revealed that signage indicating EBP was present on the doors of both residents, but there was no personal protective equipment (PPE) such as gowns or gloves available at or near the entrances to their rooms. Staff interviews confirmed inconsistent understanding and application of EBP, with some staff unaware of the reasons for EBP signage or the correct PPE requirements, and others storing gowns in resident dressers or closets rather than at the point of care. For one resident, who had recently returned from the hospital with a surgical incision and staples, there was no documentation in the electronic medical record (EMR) indicating the need for EBP, and the resident herself was unaware of the reason for the precautions. For the second resident, who had a surgical wound on his right lower leg requiring daily dressing changes, staff wore gloves but not gowns during care, and PPE was not accessible at the room entrance. The care plan for this resident specified that both gloves and gowns should be used for high-contact activities, but this was not consistently followed. Further observations in the therapy area showed that staff did not use PPE when providing direct care, such as assisting with transfers and mobility, to residents on EBP. Interviews with therapy and nursing staff revealed gaps in knowledge regarding when and where PPE should be used, particularly outside of resident rooms. The facility's policy required EBP, including gown and glove use, during high-contact activities both in resident rooms and in shared areas like the therapy gym, but this was not adhered to in practice.