Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to maintain an infection prevention and control program as required for a resident on enhanced barrier precautions (EBP). The resident, who had multiple diagnoses including type 2 diabetes, chronic ulcers, MRSA colonization, and chronic respiratory failure, was care planned for EBP due to colonization with a multidrug-resistant organism (MDRO). The care plan and Kardex specified that staff should use gowns and gloves during high-contact care activities, such as peri-care and toileting, to prevent the transmission of infection. On the day of the survey, a certified nursing assistant (CNA) was observed providing peri-care to the resident without wearing a gown, despite signage indicating EBP and the care plan's requirements. The CNA acknowledged not donning a gown at the start of care and only halted care upon noticing the surveyor. Interviews with the infection preventionist confirmed that staff should follow the resident's precautions and use appropriate personal protective equipment (PPE) during high-contact care. Additionally, the facility did not have a specific EBP policy available when requested, providing only a general transmission-based precautions policy instead.