Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure the use of gowns during high-contact resident care activities, specifically during catheter and wound dressing changes for two residents. According to the facility's own policy on Enhanced Barrier Precautions (EBP), gowns and gloves are required for all residents with wounds or indwelling medical devices during high-contact care activities. Observations revealed that staff performed catheter care and wound dressing changes for two residents without donning gowns, despite both residents having conditions that required EBP. One resident had stage 4 pressure ulcers, and the other had a urethral catheter, both of which meet the criteria for EBP according to facility policy. Further, EBP signage was not posted outside the residents' rooms as required by policy. Instead, the signs were kept inside closet doors with supplies, and staff interviews indicated inconsistent understanding and implementation of gown use and signage requirements. The Director of Nursing stated that signage was not posted on doors to maintain confidentiality, which resulted in staff not being properly reminded of the need for EBP during high-contact care activities. These actions and omissions led to non-compliance with the facility's infection prevention and control program.