Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a suprapubic catheter and a pressure ulcer, as required by physician orders and facility policy. The resident had a history of severe cognitive impairment, an indwelling urinary catheter, an unstageable pressure ulcer, and was receiving hospice services. Both the care plan and physician's order specified the need for EBP, including the use of gowns and gloves during high-contact care activities such as changing briefs or providing incontinent care. Despite these documented requirements, two CNAs were observed providing incontinent care to the resident without wearing gowns. One CNA acknowledged during an interview that EBP was required and that personal protective equipment (PPE) should have been used during the care. Facility policy, provided by the DON, clearly outlined the necessity of making gowns and gloves available and using them during high-contact care activities for residents with indwelling medical devices or wounds.