Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices by not following Enhanced Barrier Precautions (EBP) for two residents with conditions requiring such measures. For one resident with dysphagia and hemiparesis, who had a PEG tube and was cognitively impaired, a registered nurse administered medications through the PEG tube while wearing gloves but did not wear a gown, contrary to facility policy and physician orders specifying EBP during high-contact care activities. The Director of Nursing confirmed that both gloves and a gown should have been worn during this procedure. In another instance, a resident with a laryngeal stoma and severe cognitive impairment required EBP during high-contact care, including suctioning for airway clearance. An LPN entered the resident's room and did not don any PPE while the resident was coughing thick yellow sputum through the stoma. The LPN left to call for help and returned without donning PPE. The Infection Preventionist also entered and assisted with the procedure without donning PPE or performing hand hygiene prior to donning gloves. Both staff members failed to wear the required PPE during this invasive procedure, as observed and documented.