Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP), as observed during multiple care activities. One resident, admitted with an open abdominal wound and atherosclerosis with ulceration, had physician orders for EBP, including the use of gowns and gloves during high-contact care such as changing linens. A CNA was observed removing soiled linens and handling clean linens for this resident while wearing gloves but not a gown, and failed to remove gloves or perform hand hygiene before exiting the room to obtain clean linens. The CNA acknowledged awareness of the EBP order but did not follow the required protocol, and later admitted she should have worn a gown and changed gloves as indicated by the signage and orders. Further observations revealed another CNA entering a room with EBP signage to perform denture care for a resident with a PICC line. The CNA donned gloves but not a gown, handled the resident's dentures, and performed hand hygiene only after completing the task. The CNA stated she was unaware of the specific reason for the precautions and did not believe a gown was necessary for denture care. Facility leadership, including the unit manager and CNO, confirmed that gowns and gloves were required for these high-contact activities under the facility's EBP policy. The facility's policy on EBP, dated 4/6/23, specifies that gowns and gloves must be used during high-contact care activities for residents with wounds or indwelling devices, regardless of MDRO status. Examples of such activities include dressing, bathing, transferring, providing hygiene, changing linens, and wound care. The observed failures to use appropriate PPE and perform hand hygiene as required by policy and physician orders resulted in a deficiency related to infection control practices.