Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to follow established infection control guidelines for a resident with spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia, who was dependent for toileting hygiene and always incontinent of bowel and bladder. The resident was on enhanced barrier precautions due to a PEG tube, as indicated in the care plan and by a sign on the resident's door. During incontinence care, two CNAs did not wear proper PPE, specifically gowns, and placed soiled incontinence briefs and wet shorts on the floor beside the resident's bed. One CNA later confirmed only wearing gloves and was unaware that a gown was required, despite the presence of a sign indicating enhanced barrier precautions. The DON acknowledged that staff should have worn proper PPE and not placed soiled items on the floor. The facility's enhanced barrier precautions signage clearly outlined the requirement for gloves and gowns during high-contact care activities, including changing briefs and providing hygiene for residents with devices such as feeding tubes.