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F0880
F

Failure to Use Enhanced Barrier Precautions During G-Tube Care

Turlock, California Survey Completed on 06-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse failed to follow proper infection control practices for a resident with a gastrostomy tube (G-tube) during medication administration and bolus feeding. The nurse wore only gloves, omitting the required gown, despite the facility's policy and procedure on Enhanced Barrier Precautions (EBP) that mandates both gown and glove use for high-contact care activities involving residents with indwelling medical devices such as G-tubes. This was observed during a medication administration task. The resident involved had a medical history including dysphagia, cerebrovascular accident (CVA), and congestive heart failure (CHF), and was considered at high risk for infection due to the presence of the G-tube. Interviews with the nurse and the Director of Nursing confirmed that EBP, including both gown and gloves, were expected for such care activities, and that wearing only gloves was not sufficient according to facility policy. The failure to adhere to these precautions was directly observed and confirmed through staff interviews and policy review.

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