Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for residents with wounds or indwelling medical devices, such as urinary catheters. Observations revealed that staff did not consistently wear gowns during high-contact care activities, despite the presence of EBP signage and care plans indicating the need for such precautions. In multiple instances, staff provided wound care, catheter care, and assisted with transfers and hygiene for residents requiring EBP, but only wore gloves and not gowns as mandated by facility policy and CDC/CMS guidelines. Several residents with significant medical needs, including chronic wounds, indwelling catheters, and colostomies, were identified as requiring EBP. For these residents, care plans and physician orders often lacked specific instructions for EBP, and in some cases, the need for EBP was not addressed at all. Observations confirmed that staff failed to don appropriate PPE, such as gowns, during high-contact activities, and there was a lack of visible PPE carts or supplies in the rooms of affected residents. Staff interviews confirmed awareness of the requirement to wear gowns, but cited insufficient PPE availability as a barrier to compliance. Interviews with facility leadership, including the Assistant Director of Nursing and the Regional Nurse Manager, confirmed that EBP signage and PPE should be present and used for residents meeting the criteria. However, both acknowledged that the facility did not have enough PPE carts or supplies to meet the needs of all residents requiring EBP. This systemic failure to provide adequate PPE and ensure staff adherence to EBP protocols resulted in the facility not following acceptable infection control standards for multiple residents.