Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident requiring Enhanced Barrier Precautions (EBP). During an observation, a CNA assisted a male resident, who had multiple risk factors including bacteremia, chronic wounds, a PICC line, and an indwelling urinary catheter, to transfer from his wheelchair to his bed and adjusted his urinary catheter drainage bag. The CNA did not don a gown and only wore one glove on her left hand, despite being aware of the resident's need for EBP and the requirement to use both gown and gloves for direct care. PPE supplies were available outside the resident's room, and the room was clearly marked to indicate EBP was required. Interviews with the CNA and facility leadership confirmed that staff had been trained on EBP protocols, and that visual cues and PPE supplies were in place to support compliance. The CNA acknowledged her failure to fully don PPE, attributing it to not expecting the resident to request a transfer at that time and only having one glove available. Facility policy required the use of gown and gloves for high-contact care activities, including transferring and device care, for residents with wounds or indwelling medical devices.