Failure to Apply Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to apply Enhanced Barrier Precautions (EBP) while providing care to a resident with an indwelling catheter. The resident had diagnoses of acute pyelonephritis and malignant neoplasm of the endometrium, and her care plan specified the use of EBP due to the chronic Foley catheter. During observation, a nursing assistant entered the resident's room without donning EBP, despite signage and supplies being available. The nursing assistant performed high-contact care activities, including washing the resident and changing the urinary collection bag, without using appropriate EBP or sanitizing the catheter connection. Additionally, an LPN and an RN entered the room and provided direct care, such as assessing for edema, changing a dressing, and listening to lung sounds, without donning EBP. Interviews with staff revealed inconsistent understanding and application of EBP requirements, with some staff acknowledging the need for EBP and others incorrectly believing it was unnecessary. The facility's policy required gown and gloves for high-contact care for residents with indwelling medical devices, but this was not followed during the observed care activities.