Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy for a resident with a suprapubic catheter and diagnoses including benign prostatic hyperplasia and urinary retention. The resident's physician order sheet indicated EBP for device care or use of a urinary catheter, and signage outside the resident's room instructed staff to wear a gown and gloves for high-contact care activities. During morning care, a certified nursing assistant (CNA) was observed providing incontinence care and changing the resident's brief while only wearing gloves and not a gown, contrary to the posted instructions and facility policy. A licensed practical nurse (LPN) confirmed that the resident was on EBP due to the presence of the suprapubic catheter and that staff should have been wearing both gown and gloves during care. The facility's policy specifies that residents with indwelling medical devices are to be on EBP, and that high-contact care activities require both gown and gloves to reduce transmission of multidrug resistant organisms (MDROs).