Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with orders for EBP. Observations revealed that staff did not don gowns prior to providing incontinence care and wound care, despite signage and physician orders indicating the need for EBP. During incontinence care, a certified nursing assistant (CNA) cleansed feces from the resident's buttocks but did not remove gloves, perform hand hygiene, or don new gloves before proceeding to touch clean items such as the resident's brief, pajama bottoms, sheets, and wash basin. The same lack of gown use was observed during wound care. The resident involved had diagnoses including dementia, hypertension, and chronic kidney disease, and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required varying levels of assistance with personal care activities. Interviews with the staff involved and the Director of Nursing confirmed that the required infection control measures, including donning gowns and changing gloves with appropriate hand hygiene, were not followed as per facility policy and physician orders.