Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Laundry Environment
Penalty
Summary
Facility staff failed to implement adequate Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (G-tube) during a flushing procedure. Although the resident had an active order for EBP requiring gown and gloves for all cares due to the feeding tube, two licensed nurses accessed and flushed the G-tube using only gloves, omitting the required gown. Both nurses performed proper hand hygiene before and after the procedure, but did not follow the full PPE protocol as outlined in the facility's EBP policy. Interviews confirmed that staff were aware of the correct PPE requirements but did not adhere to them during the observed care. Additionally, the facility failed to maintain a sanitary environment in the laundry area. Observations revealed flaking and missing paint on the ceiling above clean laundry, clutter on the clean linen folding counter including non-laundry items, and a dirty laundry area that was cluttered and backed up with bags of resident linen and clothes stacked on the floor. This clutter blocked access to the staff hand-washing sink, eye-wash station, and laundry-soap refill. Maintenance and housekeeping staff were unaware of the extent of the issues, and one washer being out of service contributed to the laundry backlog.