Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to implement the care plan for enhanced barrier precautions (EBP) for a resident with a history of ESBL (Extended Spectrum Beta-Lactamase) resistance infection. The resident, who was always incontinent of bowel and bladder and had an abscess requiring wound care, had a physician's order and a care plan in place specifying the use of EBP, including wearing gloves and a gown during high-contact care activities such as incontinence care. Despite these documented requirements, a Certified Nurse Aide (CNA) was observed providing incontinence care to the resident without wearing a gown as mandated by the EBP protocol. Interviews with the CNA, RN, and DON confirmed that staff were aware of the EBP requirements and the care plan directives, but the CNA admitted to not following the protocol during care. The facility's policy and care plan documentation emphasized the need for individualized, measurable objectives and timetables to meet residents' needs, including infection control measures. However, the failure to adhere to the care plan and physician's order for EBP during resident care constituted a deficiency in implementing appropriate infection control practices.