Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to wear the appropriate personal protective equipment (PPE) while providing high-contact care to a resident with an indwelling medical device. The facility's policy required staff to don both gown and gloves during high-contact care activities for residents with indwelling devices, such as central lines, to prevent the transmission of multidrug-resistant organisms (MDROs). During an observation, the CNA was seen wearing only gloves while assisting the resident with morning care and transferring them to a wheelchair, despite the resident having a physician's order for enhanced barrier precautions (EBP) due to a central line for dialysis access. The signage outside the resident's room indicated that only the roommate was on EBP, and did not reflect that the observed resident also required these precautions. The registered nurse (RN) confirmed that the signage should have included the resident, as per the physician's order, and stated that the Director of Staff Development (DSD) was responsible for updating such signage. The infection prevention (IP) nurse also confirmed that staff must wear both gown and gloves for residents with EBP orders and that she was responsible for ensuring proper signage and PPE availability. Interviews with facility staff, including the CNA, RN, IP nurse, and Director of Nursing (DON), confirmed awareness of the EBP requirements and the importance of following them to prevent infection transmission. However, the failure to update signage and ensure staff compliance with PPE protocols resulted in a lapse in infection control practices for the resident with a central line. This deficiency was identified through observation, interviews, and review of facility policies and the resident's medical record.