Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) protocols for residents requiring these infection control measures. Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and therapy staff were observed providing care to residents with active physician orders for EBP—due to conditions such as wounds, urinary catheters, and intravenous (IV) lines—without wearing the required gowns, and in some cases, without proper signage indicating EBP status. For example, a CNA assisted a resident with a wound after toileting without a gown, and another CNA provided a bed bath to a resident with a urinary catheter without donning a gown, despite EBP signage being present. Additionally, therapy staff provided care to a resident with a PICC line without gowns, and there was no EBP signage outside the room to alert staff to the required precautions. Further, a nurse administered IV medication to a resident with a PICC line while only wearing gloves and not a gown, contrary to facility policy. Interviews with the Assistant Director of Nursing (ADON) and other staff confirmed that the expectation was for all staff to wear gowns and gloves when providing care to residents on EBP, and that proper signage should be posted to inform staff of the required precautions. The facility's policy clearly states that gowns and gloves are required for high-contact care activities involving devices such as urinary catheters and central lines, but these protocols were not consistently followed for the residents reviewed.