Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for two of three sampled residents when staff did not wear appropriate Personal Protective Equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). Specifically, one respiratory therapist did not wear a gown while performing oral suctioning for a resident with quadriplegia and ventilator dependence, despite an EBP sign posted on the door. The therapist initially stated that PPE was not necessary for this care, but later acknowledged that proper PPE should have been used to prevent contamination and transmission of secretions and bodily fluids. In another instance, a certified nursing assistant provided care to a resident under EBP without wearing any PPE, while the resident's family member did wear PPE. The CNA confirmed awareness that PPE was required in EBP rooms but did not comply during the observed care activity. Both residents were located in the subacute unit, where all residents were reportedly under EBP due to the risk of multidrug-resistant organisms (MDROs). Interviews with the Infection Preventionist and the Director of Nursing confirmed that EBP signage was posted for staff compliance and that not wearing PPE in these rooms posed a risk of spreading infection. Facility policy required the use of gown and gloves during high-contact resident care activities, such as device care or use, which includes tracheostomy and ventilator care. The observed failures represented a break in the facility's infection control protocol.