Failure to Implement Enhanced Barrier Precautions for Residents with Feeding Tubes
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who shared a room and both had feeding tubes for nutrition. Both residents were admitted with cerebral palsy and were assessed as severely cognitively impaired, requiring tube feeding due to dysphagia. Their care plans included interventions for EBP, but these precautions were not followed during care activities. Specifically, a registered nurse provided oral care to one resident without wearing a gown, and a certified nursing assistant was unaware of the need for EBP when providing care to both residents. Observations and interviews confirmed that staff did not utilize the required personal protective equipment (PPE) or post appropriate signage indicating the need for EBP. The Director of Nursing acknowledged that EBP should have been implemented, including the use of PPE and signage, but these measures were not in place at the time of the survey. This lapse was identified through direct observation, staff interviews, and review of medical records and care plans.