Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for a resident with an indwelling medical device. During an observation of incontinence care provided to a resident with multiple diagnoses, including dementia, chronic pulmonary edema, hepatic failure, and a stage IV sacral pressure ulcer, staff were seen performing incontinence care without donning a disposable gown, despite the presence of a gastrostomy tube. The care plan for the resident indicated a high risk for infection due to incontinence and the use of an indwelling device. Certified Nursing Assistants (CNAs) washed their hands and wore gloves but did not use a gown during high-contact care activities, such as changing briefs and cleansing the resident. Both CNAs confirmed in an interview that EBP, specifically the use of a disposable gown, was not maintained during the procedure. Facility policy required the use of gowns and gloves during high-contact care for residents with indwelling medical devices, but this protocol was not followed during the observed care event.