Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing care to a resident who was colonized with a multidrug-resistant organism (MDRO). The resident, who had a history of atrial fibrillation, mild cognitive impairment, and urinary tract infection, was under EBP to prevent the spread of the MDRO. The facility's policy required staff to don gown and gloves during high-contact care activities, such as changing linens or any care that could transfer MDROs to staff hands or clothing. During observation, the RN administered oral medications and eye drops to the resident without wearing a gown or gloves. While administering the eye drops and adjusting the resident's pillow and pillowcase, the RN's uniform top came into contact with the resident's bed linens, which constituted high-contact care. The RN later acknowledged that PPE should have been worn during these activities, and the Director of Nursing confirmed this requirement according to facility policy.