Failure to Implement Enhanced Barrier Precautions and Lack of Transmission-Based Precaution Policies
Penalty
Summary
A deficiency was identified when staff failed to implement proper infection prevention and control practices for a resident on Enhanced Barrier Precautions due to the presence of extended-spectrum beta-lactamase-producing bacteria in their urine. During an observation, a Certified Nurse Aide provided incontinent care involving exposure to urine and feces without donning a gown, as required by the posted Enhanced Barrier Precaution signage. The signage clearly indicated that gloves and gowns were to be worn during high-contact resident care activities, such as dressing, hygiene, and changing briefs. The Certified Nurse Aide acknowledged awareness of the signage but was uncertain about which resident required precautions and did not follow the required protocol during care. Interviews with facility staff, including the Certified Nurse Aide, Registered Nurses, the Director of Nursing, the Infection Preventionist, and the Medical Director, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions. However, it was revealed that the facility did not have specific written policies and procedures for Enhanced Barrier Precautions or for other types of transmission-based precautions, such as airborne, droplet, and contact precautions. Staff reported relying on CDC guidelines and posted signage but lacked formalized facility policies to guide their actions. The resident involved had significant cognitive impairment, was frequently incontinent of bowel and bladder, and had a care plan indicating the need for staff to use personal protective equipment per the posted precaution card. Despite these documented needs and the presence of signage and PPE supplies, the lack of clear, facility-specific policies and procedures contributed to inconsistent implementation of infection control measures, as evidenced by the observed failure to use appropriate PPE during high-risk care activities.