Failure to Implement Enhanced Barrier Precautions and Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) in a timely and consistent manner for three residents who required these precautions due to the presence of indwelling medical devices or open wounds. For one resident with a Foley catheter and skin tears requiring wound care, EBP was not initiated upon admission as required by facility policy, but instead was delayed for several days. The Director of Nursing confirmed that EBP should have been implemented at the time of admission based on the resident's clinical needs. Another resident with a percutaneous endoscopic gastrostomy (PEG) tube and orders for EBP did not receive proper infection control during medication administration and PEG site care. The registered nurse providing care wore only gloves, omitting the required gown, and failed to change gloves or perform hand hygiene between different care tasks, including medication administration, dressing change, and eye drop administration. The nurse incorrectly believed that gloves alone were sufficient since the resident did not have an active infection, despite facility policy requiring both gown and gloves for high-contact care activities under EBP. A third resident with chronic wounds and an order for EBP was not consistently provided with the required personal protective equipment by staff. Interviews revealed that both nursing and aide staff were unclear about when EBP was necessary, with some staff believing that gowns were only needed during wound care or if an infection was present. Observations confirmed that signage was present but not always understood or followed by staff. Facility policy specified that EBP, including gown and gloves, should be used during high-contact care activities for residents with wounds or indwelling devices, but this was not consistently implemented.