Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to follow established infection prevention and control protocols while transferring a resident who was on Enhanced Barrier Precautions (EBP) due to a urinary catheter and risk for urinary tract infections. During the transfer from wheelchair to bed using a mechanical lift, CNA A wore gloves but did not wear a gown, and CNA B did not wear any personal protective equipment (PPE) at all. The resident’s care plan and signage outside the room clearly indicated the need for gown and gloves during high-contact care activities, including transfers, for residents on EBP. Interviews with the CNAs revealed that CNA A was aware of the requirement but forgot to don the gown, while CNA B was unaware that the resident was on EBP and therefore did not use any PPE. The Director of Nursing (DON) confirmed that both CNAs should have worn gloves and gowns during the transfer, as per facility policy and posted instructions. Facility policy specified that EBP requires gown and gloves for high-contact activities for residents with indwelling medical devices, such as urinary catheters.