Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to adhere to standard infection control practices regarding the use of gowns during care for residents on Enhanced Barrier Precautions (EBP). Observations revealed that staff did not wear gowns while providing high-contact care to three residents who were on EBP due to conditions such as a history of Candida Auris, end stage renal failure with IV access, and a history of multidrug-resistant organisms. Specifically, two CNAs provided hygiene care to a resident with a history of Candida Auris without donning gowns, despite EBP signage being present. Another CNA provided incontinence care to a resident with an AV fistula and IV midline catheter, who was also receiving IV antibiotics, without wearing a gown. Additionally, a nurse checked vital signs at the bedside of a resident with a wound, indwelling urinary catheter, and history of KPC, again without wearing a gown, even though EBP signage was posted. Interviews and record reviews confirmed that these residents were on the facility's EBP list and that staff were expected to wear gowns and gloves during high-contact care activities, as outlined in the facility's EBP policy and posted signage. The policy specifically required gown and glove use for activities such as dressing, bathing, hygiene, incontinence care, and device care for residents on EBP. Despite these clear expectations and procedures, staff failed to consistently implement the required infection control measures during the observed care activities.