Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to Enhanced Barrier Precautions (EBP) during high-contact care activities for multiple residents with indwelling medical devices or wounds. Observations revealed that an LPN administered medications through a PEG tube to a resident with an active EBP order without wearing a gown, despite signage on the door and the nurse's acknowledgment of the requirement. Similarly, a wound care nurse and a CNA provided wound care and assistance with a sit-to-stand lift for another resident with a chronic wound, also under EBP, without donning gowns as instructed by posted signage. In another instance, a wound care nurse performed PEG site care for a resident with moderate cognitive impairment and an EBP order, again without using the required gown and gloves, even though PPE was readily available nearby. Record reviews confirmed that all affected residents had current orders for EBP due to the presence of wounds or indwelling devices, and facility policy required the use of gowns and gloves during high-contact care activities for these residents. Staff interviews further confirmed awareness of the EBP requirements and the purpose of PPE use, yet the required precautions were not followed during the observed care activities.