Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to follow infection control practices during activities of daily living (ADL) care for one resident who was on enhanced barrier precautions (EBP) due to a venous/stasis ulcer related to peripheral vascular disease. The resident was assessed as dependent for toileting, dressing, and transfers, and had a chronic wound requiring dressing applications. Facility policy and posted signage required staff to wear both gown and gloves when providing high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, and incontinence care for residents on EBP. On the observed date, a certified nursing assistant provided incontinence care, changed a soiled brief, dressed the resident, and changed soiled bed linens while only wearing gloves and not a gown, as required. Subsequently, a licensed practical nurse assisted with transferring the resident from bed to wheelchair, also without wearing a gown. Interviews with staff confirmed their awareness of the EBP requirements and the facility's policy, but the required use of gowns during high-contact care was not followed during the observed care activities.