Failure to Implement Enhanced Barrier Precautions During High-Contact Procedure
Penalty
Summary
A deficiency was identified when a registered nurse failed to implement Enhanced Barrier Precautions (EBP) during a high-contact procedure for a resident with indwelling medical devices. Specifically, during a chest tube dressing change, the nurse donned gloves but did not wear a gown as required by EBP protocols. The resident had both a urinary Foley catheter and a chest tube, and there was an active physician's order for EBP due to these devices. An enhanced barrier sign was posted outside the resident's room, indicating the need for these precautions. The observation was made during a dressing change, where the nurse removed the old dressing, cleansed the area, changed gloves, and applied a new dressing without donning a gown. The failure to use a gown during this high-contact activity was contrary to the requirements outlined in the CMS memo on EBP, which mandates gown and glove use for residents with indwelling devices during such procedures. The deficiency was confirmed through observation, clinical record review, and staff interviews.
Plan Of Correction
1. Facility is unable to retroactively correct staff member entering room to give high-contact care with incorrect PPE. 2. An audit of all residents on EBP was completed to ensure proper signage to include proper PPE required. 3. All nursing staff will be educated on EBP, including what PPE is required and when it is required. 4. Administrator or designee will complete a random audit of residents on EBP 4x a week for 4 weeks and weekly for 2 months to ensure proper PPE is being used and at the correct times. Results will be reviewed by QAPI committee for further action planning as necessary.