Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to the facility's infection control practices and policies for a resident who was on Enhanced Barrier Precautions (EBP). During wound care and bathing, a Certified Nursing Assistant (CNA) did not wear a gown as required, despite an EBP sign posted on the resident's door indicating the need for gown and glove use during high-contact activities such as bathing and wound care. The Registered Nurse (RN) performing wound care did wear the appropriate personal protective equipment (PPE), but the CNA, who was assisting with positioning the resident and providing a bed bath, did not. The CNA later acknowledged awareness of the EBP requirements but admitted to not wearing a gown during the care activities. The resident involved had significant medical needs, including a stage 4 pressure ulcer, an indwelling urinary catheter, a feeding tube, and severe cognitive impairment. Review of the resident's care plan and medical orders revealed no documentation or orders for Enhanced Barrier Precautions, although the infection prevention nurse maintained a separate list and ensured signage was present. The Director of Nursing confirmed that EBP was not typically documented in the care plan or as a physician order, but expected staff to follow posted EBP instructions.