Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow physician orders and care plan interventions for Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. The resident, who had diagnoses including unspecified dementia, anxiety disorder, and adult failure to thrive, was dependent for activities of daily living, frequently incontinent of urine, always incontinent of bowel, and received the majority of nutrition via a PEG tube. Physician orders and the care plan required the use of EBP, including donning gowns and gloves during high-contact care activities such as incontinence care and tube feeding management. During observation, two CNAs and an LPN provided incontinence care and managed the resident's tube feeding without donning isolation gowns, despite clear signage and facility policy requiring this PPE for such activities. The staff's clothing came into contact with the resident, bed, and linens during care. Interviews confirmed that the staff did not wear the required gowns, and the LPN was unaware that a gown was necessary for tube feeding care. The facility's policy, updated in 01/2025, specified that EBP must be used for residents with indwelling medical devices, including feeding tubes, during high-contact care activities.