Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow established infection prevention and control practices related to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and wounds. On multiple occasions, certified nurse aides (CNAs) and a licensed nurse (LN) did not wear required gowns while performing high-contact care activities, such as transferring a resident with wounds and a urinary catheter using a total lift, and administering medications through a gastrostomy tube. These actions were observed despite clear physician orders and care plans specifying the use of gowns and gloves for such activities under EBP protocols. The facility's infection control policy required the use of gowns and gloves during high-contact care for residents at increased risk for multidrug-resistant organism (MDRO) transmission, including those with wounds, catheters, nephrostomy tubes, and feeding tubes. Staff and administrative nurses verified that gowns should have been worn during these care activities, and signage and supplies were present at the point of care. The failure to adhere to these precautions was confirmed through direct observation, record review, and staff interviews.