Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. The facility's policy and physician orders required the use of gloves and gowns during high-contact care activities, such as changing briefs, toileting, and catheter care, for residents under EBP. Despite these requirements, a staff member was observed entering the resident's room and performing these high-contact care activities without donning a gown, as mandated by both facility policy and CDC guidelines. The resident involved had a medical history that included chronic kidney disease, pyelitis cystica, and obstructive and reflux uropathy, and was at increased risk for infection due to the presence of an indwelling Foley catheter. The resident's care plan and physician orders specifically called for EBP, including the use of appropriate PPE during high-contact care activities. A sign was posted on the resident's door indicating the need for gloves and gowns for such activities, yet this protocol was not followed during the observed care. Interviews with the LPN who provided care confirmed awareness of the EBP requirements but revealed non-compliance, as the LPN admitted to not wearing a gown during catheter care. The Director of Nursing also confirmed that staff had been educated on EBP protocols and that it was her expectation for staff to follow these precautions for residents with catheters or wounds. Despite this, the required infection control measures were not implemented during the observed incident.