Failure to Follow Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow Enhanced Barrier Precautions (EBP) during the administration of medication via a gastrostomy tube for a resident with hemiplegia and gastrostomy status. The resident was severely cognitively impaired, totally dependent on staff for nutrition, and required EBP during high-contact care activities due to the presence of an indwelling medical device. The resident's care plan specified the need for EBP, including the use of gowns and gloves during high-contact activities such as device care. During an observed medication administration, the LVN performed hand hygiene and donned gloves but did not wear a gown as required by the resident's care plan and facility policy. Interviews with the LVN, other nursing staff, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed that staff were aware of the EBP requirements for residents with indwelling devices, and that personal protective equipment (PPE) was available on the linen carts. The LVN acknowledged the oversight and the importance of following EBP to prevent the spread of infection. Facility policy required the use of gowns and gloves for residents with devices such as feeding tubes, but this protocol was not followed during the observed event.