Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow proper infection control practices for a resident who was under Enhanced Barrier Precautions (EBP) due to wounds. The resident, who had quadriplegia, a history of pressure ulcers, an indwelling urinary catheter, and incontinence of stool, required staff to don both gowns and gloves before providing high-contact care, as indicated by signage in the room and facility policy. Multiple video recordings over several days showed various staff members, including nurses and CNAs, providing direct care to the resident while wearing gloves but not donning the required protective gowns. These observations were verified by the facility's Administrator and DON during a review of the footage. The facility's policy on Transmission Based Precautions clearly stated that both gowns and gloves were required for high-contact care activities such as hygiene, linen changes, and wound care. The failure to adhere to these procedures was identified through medical record review, direct observation, staff interviews, and review of facility investigation materials.