Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a recent history of open heart surgery and a midline sternum surgical wound was not provided with proper infection control measures during personal care. The resident required Enhanced Barrier Precautions (EBP) as indicated by physician orders and signage on the resident's door, specifying the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care activities such as toileting and changing bed linens. Despite these requirements, a Certified Nursing Assistant (CNA) was observed providing direct personal care to the resident while only wearing gloves and not a gown, contrary to the EBP protocol. The CNA stated a lack of awareness regarding the resident's EBP status at the time of care and admitted to not wearing a gown during the incident. Interviews with facility staff, including the wound nurse, confirmed that the facility follows CDC guidelines for EBP and that staff are trained to recognize signage and use appropriate PPE. However, the care plan for the resident did not specifically address EBP, and the CNA did not adhere to the required infection control practices during the observed care event.