Failure to Follow Enhanced Barrier Precautions During High Contact Care
Penalty
Summary
Facility staff failed to adhere to infection control standards by not following Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. According to facility policy, EBP requires staff to wear gowns and gloves during high contact care activities for residents with indwelling medical devices, such as catheters, to reduce the transmission of multidrug-resistant organisms (MDROs). The policy and signage outside the resident's room clearly indicated the need for gown and glove use during activities like dressing, bathing, transferring, and device care. On the observed date, two certified nurse aides (CNAs) donned gloves but did not wear gowns while providing high contact care, including transferring the resident with a mechanical lift. The signage indicating EBP requirements was present and visible outside the room, and a storage bin with appropriate PPE was available. Despite these measures, the CNAs entered the room and performed care without the required gowns. One CNA later stated she was unsure of the meaning of the signage or to which resident it applied. Interviews with nursing and infection control staff confirmed that the resident was on EBP due to the presence of an indwelling catheter and that staff should have worn both gowns and gloves during care. The involved CNA had completed orientation and received education on hand hygiene, PPE donning, and EBP prior to the incident. The resident was cognitively intact, aware of their catheter, and reported occasional leakage. The failure to follow EBP was directly observed and acknowledged by facility leadership.