Failure to Implement Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to implement Enhanced Barrier Precautions (EBP) as required while administering medications through a feeding tube to a resident. During the observed medication administration, the LPN performed hand hygiene and donned gloves but did not wear a gown, despite an EBP sign being posted on the resident's door. The LPN acknowledged after the observation that both a gown and gloves were required for this procedure under EBP protocols. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the resident was on EBP due to the presence of a feeding tube and that facility policy required both gown and gloves for such care. The resident had significant medical conditions, including end stage kidney disease, diabetes mellitus, and difficulty swallowing, and was assessed as having moderate cognitive impairment. Documentation in the care plan and physician's orders also indicated the need for EBP related to the feeding tube. The failure to follow established EBP protocols was directly observed and confirmed by facility leadership.