Failure to Follow Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow enhanced barrier precautions (EBP) while administering medications and feeding via gastrostomy tube (g-tube) to a resident who required these precautions. The resident, a cognitively intact female with epilepsy, muscle weakness, dysphagia, and a g-tube, was care planned for EBP due to her feeding tube. The care plan specified that staff must don gown and gloves during high-contact care activities, including device care such as g-tube management, and that EBP signage and supplies should be present and accessible in the resident's room. During a medication pass, the RN did not wear a gown while checking g-tube placement, administering medications, and starting tube feeding for the resident. The RN stated it was her first day working with the resident and was unaware of the EBP status, did not see the EBP sign, and did not notice the PPE supplies in the room. However, subsequent interviews confirmed that the EBP sign was posted and PPE supplies were available in the resident's room as required by facility policy. Facility policies and the resident's care plan both required the use of gown and gloves for high-contact care activities involving indwelling medical devices such as a g-tube. The failure to don appropriate PPE during these activities constituted a breach of the infection prevention and control program, as it did not adhere to established protocols designed to prevent the transmission of communicable diseases and infections.