Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow enhanced barrier precautions for a resident who was at high risk for infection. The resident, a male with diagnoses including acute hematogenous osteomyelitis, end stage renal failure, dependence on dialysis, and severe sepsis with septic shock, was under physician-ordered enhanced barrier precautions due to multiple risk factors such as pressure wounds, cellulitis, a foley catheter, and a dialysis access permcath. The care plan and physician orders specified that staff were to use gowns and gloves during high contact care activities to reduce the risk of multidrug-resistant organism (MDRO) transmission. During an observation, the LVN entered the resident's room, which was clearly marked for enhanced barrier precautions, and donned gloves but failed to put on a gown before approaching the resident and handling the foley catheter tubing and balloon inflation port. The LVN later acknowledged forgetting to don the gown, despite understanding the requirement to wear both gloves and gown before entering the room for contact with the resident. Facility policy and CDC guidelines both require the use of appropriate personal protective equipment (PPE), including gowns and gloves, for all interactions that may involve contact with the resident or their environment under transmission-based precautions.