Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not properly implementing Enhanced Barrier Precautions (EBP) for a resident requiring such measures. During an observation, a certified nursing assistant (CNA) responded to a call light for a resident with a suprapubic urinary catheter and a history of multidrug-resistant organism (MDRO) colonization. The CNA donned only a mask and entered the room, later joined by another CNA and a private sitter, both of whom wore masks and gloves but not gowns. These staff members had just completed bathing and dressing the resident and were preparing to transfer him using a mechanical lift, all of which are high-contact care activities requiring both gloves and gowns per EBP protocols. When questioned, the staff indicated they believed gowns were not necessary for this type of care, despite signage on the door and facility policy indicating otherwise. Further interviews revealed that the registered nurse (RN) assigned to the unit also misunderstood the requirements for EBP, stating that gowns were only needed for airborne precautions and not for residents with MDROs or indwelling catheters. The Infection Preventionist (IP), who also served as Assistant Director of Nursing and Staff Development, confirmed that staff had been educated on EBP but acknowledged that there was no ongoing surveillance process to monitor adherence to PPE protocols. Additionally, the list of residents requiring EBP was found to be inaccurate, missing two residents who should have been included. Record review for the affected resident showed active orders for EBP due to the presence of a suprapubic catheter and a history of MDRO, with care plans reflecting the need for assistance with activities of daily living. Facility policy required gowns and gloves to be available near or outside the resident's room and mandated staff compliance with EBP during high-contact care activities. However, during the survey, PPE supplies were not observed at the point of care, and staff failed to follow established protocols, resulting in a breakdown of infection control practices.