Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who were identified as requiring these precautions due to the presence of indwelling medical devices. According to the facility's EBP policy, staff are required to wear gowns and gloves during high-contact care activities for residents at high risk of Multidrug Resistant Organism (MDRO) acquisition, such as those with wounds or indwelling devices. Both residents had care plans and physician orders specifying the need for EBP during high-contact care, including activities involving their indwelling urinary catheters. Despite clear signage and documented orders, staff did not consistently follow EBP protocols. On separate occasions, a CNA and an RN emptied the urine collection bags of the two residents without wearing gowns, as required by policy. Both staff members acknowledged that gowns should have been worn during these activities. The Director of Nursing confirmed that all staff are expected to use gowns and gloves during high-contact care for residents on EBP.