Failure to Implement and Educate Staff on Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff were properly educated in and implemented Enhanced Barrier Precautions (EBP) during high-contact care for a resident with a stage 3 sacral pressure injury. Observations revealed that staff, including an RN and multiple CNAs, did not consistently wear gowns as required during wound care and other high-contact activities, despite gloves being used. During wound care, the RN did not don a gown and her clothing came into contact with the resident's bed linens. The resident's care plan and physician orders specifically required EBP, including the use of gowns and gloves during high-contact care, but these precautions were not followed. Interviews with staff indicated a lack of knowledge and awareness regarding EBP requirements. Several CNAs were unfamiliar with what EBP entailed, how to identify which residents required EBP, or what personal protective equipment (PPE) was necessary. Assignment sheets and signage were not consistently used or noticed, and staff did not always perform hand hygiene or change gloves appropriately during care. One CNA was observed providing incontinence care, changing clothing, and manipulating a feeding tube without wearing a gown, performing hand hygiene, or changing gloves, despite EBP signage being present in the resident's closet. The Director of Nursing (DON) confirmed that EBP was required for residents with wounds, invasive lines, or indwelling devices, and that gowns and gloves should be used during high-contact care. However, the DON was unable to provide documentation of when EBP education was provided to staff or which staff had received it. Agency staff also reported not receiving EBP education prior to providing care. Facility policy required EBP for residents with wounds or indwelling devices, specifying gown and glove use for high-contact activities, but this policy was not consistently implemented.