Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for a resident with a stage 4 pressure ulcer and an indwelling urinary catheter. According to facility policy, EBPs require staff to use gowns and gloves during high-contact care activities for residents with certain conditions, including wounds and catheters. Observations revealed that a certified nursing assistant (CNA) emptied the resident's urinary catheter bag while wearing gloves but did not don a gown, contrary to policy requirements. The CNA stated she was not required to wear a gown for catheter care. Additionally, a licensed vocational nurse (LVN) provided wound care to the same resident without wearing a gown and acknowledged this omission during an interview. Interviews with the infection preventionist, director of nursing, and executive director confirmed that EBPs, including the use of gowns and gloves, were expected for residents with catheters, wounds, or gastrostomy tubes. The resident involved had a medical history of type 2 diabetes, a stage 4 pressure ulcer, and obstructive and reflux uropathy, and was dependent on staff for all activities of daily living. Despite clear facility policy and leadership expectations, staff did not consistently follow EBP protocols during high-contact care activities for this resident.