Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow physician orders and facility policy regarding the use of personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions. Specifically, a licensed vocational nurse was observed changing the resident's incontinent brief without wearing complete PPE, despite the resident being on enhanced barrier precautions due to diagnoses including sepsis, urinary tract infection, and chronic kidney disease. The resident required maximal assistance for activities of daily living and had moderately impaired cognitive skills, as documented in the Minimum Data Set. Interviews with staff revealed a lack of adherence to PPE protocols, with one nurse admitting to not wearing full PPE because she was in and out of the room and forgot to put it back on. There was also confusion among staff regarding the type of transmission-based precaution in place, with one nurse incorrectly identifying the precaution as droplet rather than enhanced barrier. Facility policy clearly stated that enhanced barrier precautions require the use of gowns and gloves during high-contact care activities, such as changing briefs, to prevent the spread of multi-drug resistant organisms.