Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for a resident with a surgical incision, as required to prevent the transmission of communicable diseases and infections. Observations revealed that staff did not consistently use personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities including transfers and toileting. Specifically, a licensed nurse assisted the resident with toileting without donning PPE, and a certified nurse aide performed multiple transfers and adjusted the resident’s environment without wearing a gown or gloves or sanitizing hands afterward. The resident was on EBP due to a surgical incision, and signage was posted indicating the need for precautions, but staff did not adhere to these requirements during care. Interviews with staff and administrative nurses confirmed that monthly education on EBP and infection control was provided, and that staff were expected to use PPE during high-contact care. However, both the licensed nurse and the certified nurse aide failed to follow these protocols during observed care activities. The facility’s policy specified that EBP and PPE use were required for residents with certain conditions, including surgical incisions, during activities such as transfers, toileting, and wound care, but these procedures were not followed as observed.