Failure to Follow Enhanced Barrier Precautions During Tube Feeding Care
Penalty
Summary
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with a feeding tube. The resident, who was cognitively intact and had diagnoses including dysphagia following cerebral infarction, pharyngeal dysphagia, diverticulum of esophagus, gastrostomy, anxiety, and gastroesophageal reflux, was on enteral feeding and had specific orders and care plan instructions for EBP. Facility policy and signage on the resident's door required staff to wear gloves and a gown during high-contact care activities, including tube feeding management. During an observed medication and feeding administration, a registered nurse washed her hands and donned gloves but did not wear a gown as required by EBP. The nurse acknowledged forgetting to wear the gown and confirmed the resident was on EBP due to the feeding tube and infection risk. Interviews with other staff and the assistant director of nursing/infection control nurse confirmed the expectation to use gloves and gowns for such care, in line with facility policy and recent staff training. The failure to wear a gown during high-contact care for a resident with an indwelling medical device constituted a breach of the facility's infection prevention and control program.