Failure to Follow Enhanced Barrier Precautions During Resident Transfers
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy for two residents who required these precautions due to the presence of indwelling Foley catheters and, in one case, a chronic wound. According to the facility's policy, staff are required to use gowns and gloves during high-contact resident care activities, such as transferring residents or providing wound care, to prevent the transfer of multi-drug resistant organisms (MDROs). For one resident, after wound care was completed with appropriate PPE, a CNA removed her gown and gloves, performed hand hygiene, and applied new gloves, but then assisted with transferring the resident using a ceiling lift without donning a gown as required by EBP protocol. In another instance, two CNAs assisted a second resident, also on EBP due to an indwelling Foley catheter, to transfer from bed to wheelchair. The CNAs wore gloves but did not wear gowns during the transfer, contrary to the facility's EBP policy. An administrative staff member confirmed during an interview that staff are expected to wear gowns during high-contact care activities for residents on EBP. These observations demonstrate that staff did not consistently follow the established infection prevention and control procedures for residents requiring EBP.