Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program related to Enhanced Barrier Precautions for two residents. For one resident with a history of MRSA infection, wound care orders included the use of Enhanced Barrier Precautions due to the presence of a wound and a Foley catheter. During an observed wound treatment, two licensed nurses did not properly discard their used gowns in a protective bag as required, instead carrying the exposed gowns outside the resident's room and placing them in an open trash box attached to the treatment cart. Both staff members confirmed this practice at the time of the observation. For another resident with hemiplegia, respiratory failure, malnutrition, and requiring continuous oxygen therapy, an indwelling urinary catheter, and a feeding tube, a nurse aide was observed providing personal care without wearing the required personal protective equipment (PPE). Upon interview, the aide stated she was unaware that a gown was required unless performing wound or catheter care. These findings were based on direct observation, staff interviews, and review of clinical records and facility policies.