Failure to Implement Enhanced Barrier Precautions and Maintain Tube Feed Sanitation
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds and a feeding tube. Multiple observations showed that staff, including registered nurses and certified nursing assistants, did not wear gowns while providing direct care such as changing bed linens and briefs, or when reconnecting the resident's tube feed. The resident reported that staff wore gloves but not gowns during care. Staff interviews revealed inconsistent knowledge about the requirement to use gowns as part of EBP for residents with tube feeds and chronic wounds. Additionally, the resident's tube feed was observed to be disconnected and left uncapped, exposing the end of the tube to air. Both nursing staff and the regional nurse consultant confirmed that the tube should be capped when not in use to prevent contamination. The facility had a system in place to identify residents requiring EBP and provided gowns and masks outside the resident's room, but these precautions were not consistently followed by staff during care activities.