Failure to Adhere to Enhanced Barrier Precautions and Proper Resident Identification
Penalty
Summary
The facility failed to ensure that nursing staff adhered to its enhanced barrier precautions (EBP) policy during medication administration for two residents. Specifically, during medication passes, one nurse performed hand hygiene but did not don a gown before providing care to a resident with an EBP sign posted, while another nurse donned gloves but failed to wear a gown before measuring vital signs and administering medication to another resident under EBP. Both nurses acknowledged the requirement to use gloves and gowns as indicated by the EBP signage, with one nurse stating she forgot to put on the gown. Facility policies reviewed indicated that staff are required to follow established infection control procedures and receive education on proper techniques. Additionally, the facility did not provide a proper identifier for a resident on EBP due to an indwelling urinary catheter. The resident's care plan required appropriate infection control precaution signs to be placed next to the door entrance with the room number, but during observation, no such identifier was present. Both the nurse and the Infection Preventionist confirmed the absence of the EBP indicator, and the Director of Nursing acknowledged that signage should be placed above the resident's bed or outside the door as per the care plan intervention. Facility policy stated that the Infection Preventionist or designee is responsible for determining and implementing appropriate notification for EBP.