Failure to Follow Enhanced Barrier Precautions During Feeding Tube Medication Administration
Penalty
Summary
A registered nurse failed to adhere to the facility's Enhanced Barrier Precautions (EBP) policy while administering medications through a jejunostomy tube to a resident. The resident, who had a history of feeding difficulties, oropharyngeal dysphagia, cerebral infarction, and required a feeding tube for nutrition and medication, was under EBP due to the presence of an indwelling medical device. The nurse donned gloves but did not put on a gown before performing the high-contact activity, despite clear signage and available personal protective equipment (PPE) outside the resident's room indicating that both gloves and a gown were required for such care activities. The nurse acknowledged during an interview that she should have worn a gown and attributed the oversight to nervousness. Both the Director of Nursing and the facility's Infection Preventionist confirmed that the expectation and policy require staff to wear gloves and gowns when providing care involving feeding tubes to prevent the spread of infections. A review of the facility's policy further supported that device care, such as feeding tube use, necessitates the use of both gloves and a gown as part of EBP.