Failure to Follow Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
Surveyors observed multiple instances where staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact resident care activities. In several cases, staff—including registered nurses, wound care physicians, nurse managers, wound technicians, certified nursing assistants, and advanced practice nurse practitioners—did not wear required personal protective equipment (PPE) such as gowns and gloves while performing wound care, incontinence care, catheter care, and tube feeding care. These lapses were directly observed during wound treatments for residents with pressure injuries, indwelling catheters, and feeding tubes, despite clear signage and care plans indicating the need for EBP. Specific incidents included a registered nurse performing wound care on a resident with multiple pressure injuries and a Foley catheter without donning a gown, as well as a wound care physician conducting wound debridement with only one glove and using an ungloved hand. Certified nursing assistants were seen providing incontinence and peri care without changing gloves or performing hand hygiene between tasks, and in some cases, did not wear gowns as required. Additionally, a licensed practical nurse was observed flushing a resident's feeding tube without wearing a gown, and there was no EBP sign on the resident's door, contrary to facility policy. Interviews with staff and leadership confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents on EBP, and that signage should be present to alert staff to these requirements. Staff acknowledged lapses as oversights or due to missing signage, and leadership reiterated the policy requirements. The surveyors documented these deficiencies as failures to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases.