Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) protocol for a resident with an indwelling catheter. During an observed care activity, two unlicensed staff members changed the resident's incontinence brief without wearing gowns, despite clear signage and facility policy requiring both gowns and gloves for such high-contact care activities. The resident's care plan indicated the presence of an indwelling catheter, and the EBP document posted at the room entrance specified the need for gown and glove use during incontinence care. Both unlicensed staff members confirmed in interviews that they did not wear gowns during the care activity and acknowledged that they should have done so according to EBP guidelines. The resident also verified that staff did not wear gowns and stated that this had been a consistent practice. Interviews with a licensed nurse and the facility's infection preventionist further confirmed that residents with indwelling catheters are placed on EBP and that staff are required to wear gowns and gloves during incontinence care, as outlined in both facility policy and state guidance.