Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program on one unit by not adhering to Enhanced Barrier Precautions (EBP) for two residents with conditions requiring such measures. For one resident with a history of chronic foot ulcers, recent amputation, and surgical wounds, staff were observed providing direct care, including assisting with footwear and transfers, while only wearing gloves and a surgical mask, but not donning a gown as required by the facility's EBP policy. The EBP signage and PPE supplies were present, but the staff did not follow the full PPE protocol during high-contact care activities. Similarly, another resident with an indwelling urinary catheter was placed on EBP, but staff providing high-contact care, such as toileting and changing, were observed wearing only gloves and a surgical mask, omitting the required gown. The Assistant Director of Nursing confirmed that both residents were on EBP due to their medical conditions and that full PPE, including gowns, should have been used during care. These observations demonstrate a failure to consistently implement the facility's EBP policy for residents at increased risk of MDRO transmission.