Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) as required for two residents. One resident, admitted with a gastrostomy tube and dementia, had physician orders and a care plan indicating the need for EBP due to the presence of an indwelling medical device. During personal care, a CNA provided hygiene without wearing a gown, despite signage and care guides indicating EBP was required. The CNA initially believed the other resident in the room was on EBP, but upon review of the care guide and door signage, it was confirmed that the resident receiving care was the one requiring EBP. The CNA acknowledged the failure to don a gown during high-contact care activities. Another resident with a sacral pressure wound had orders and a care plan for EBP. During a wound dressing change, there was no signage indicating EBP, and no PPE was available at the room entrance. The treatment nurse did not wear a gown while performing the dressing change, even though fecal material was present near the wound site. The nurse stated EBP was not needed because the wound was not colonized with infectious organisms, contrary to facility policy and physician orders that required EBP for wounds regardless of colonization status. Interviews with facility leadership, including the Infection Preventionist, Medical Director, DON, and Administrator, confirmed that EBP should have been implemented for both residents as per policy and orders. The failure to use gowns during high-contact care activities for residents with indwelling devices and wounds constituted a breach of the facility's infection prevention and control program.