Failure to Inform Family and Enforce Enhanced Barrier Precautions
Penalty
Summary
The facility failed to uphold its infection prevention and control program for one resident by not informing the resident's family that the resident was on Enhanced Barrier Precautions (EBP). The resident, who had multiple diagnoses including diabetes with neuropathy, aortic stenosis, and a urinary tract infection, was admitted with a stage two pressure ulcer and was placed on EBP due to the wound. The care plan indicated the use of EBP, and signage was posted outside the resident's room to indicate these precautions. Despite these measures, a family member was observed at the resident's bedside, leaning over and making direct contact with the resident's linens and clothing without wearing a gown or gloves. The family member reported that no facility staff had explained EBP, its purpose, or the need for personal protective equipment (PPE) during high-contact care activities. The family member stated that both she and her sister had been visiting and assisting with the resident's care since admission, but neither had been informed about the EBP requirements. The Director of Nursing confirmed that the facility's protocol required notifying family representatives about EBP at admission or when implemented, and that staff were expected to provide CDC educational materials and ensure compliance with PPE use during high-contact activities. The facility's policy also specified that residents and their families should be notified about EBP and provided with relevant information. However, in this case, the family was not informed, and staff did not ensure that EBP protocols were followed during family visits.