Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program by not implementing enhanced barrier precautions (EBP) during high-contact care activities for two residents. For one resident with chronic wounds, a posted EBP sign was observed outside the room, but no PPE cart or gowns were available nearby. A CNA assisted the resident with toileting and transferring while only wearing gloves, and stated that the resident was not on EBP and that the sign only indicated extra precautions were needed. The resident's treatment record confirmed EBP was required due to chronic wounds. For another resident with a history of traumatic subdural hemorrhage, MRSA infection, wounds, and an indwelling catheter, staff were observed preparing to transfer the resident without wearing any PPE, despite an EBP sign posted outside the room. Both the CNA and LPN involved were unsure about the need for PPE, and no gowns were available near the room. The Director of Nursing later confirmed that PPE, including gown and gloves, should be worn during high-contact care for residents on EBP, and that transferring and toileting are considered high-contact activities.