Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
During a complaint investigation, surveyors identified that the facility failed to maintain infection prevention and control practices in accordance with its own policy for enhanced barrier precautions for one resident. The resident in question had multiple active diagnoses, including sepsis, chronic osteomyelitis, gastrostomy malfunction, and several unhealed pressure ulcers, and was under enhanced barrier precautions as indicated by signage outside their room. The resident's care plan and medical orders specifically required the use of enhanced barrier precautions, including gown and glove use during high-contact care activities. On three separate occasions, staff members provided hands-on care to the resident without wearing gowns, despite the posted signage and facility policy. Observations included a respiratory therapist adjusting respiratory equipment and physically assisting the resident while only wearing gloves, and a registered nurse manager assisting with changing the resident's gown without donning a new gown after having removed it to leave the room. The resident was noted to be diaphoretic and minimally clothed during these interactions, increasing the likelihood of direct contact with bodily fluids and skin. Interviews with the involved staff revealed a lack of awareness or lapses in adherence to the enhanced barrier precautions policy. The respiratory therapist, who was new to the facility, did not notice the signage and believed a gown was unnecessary for auscultating breath sounds. The registered nurse manager was unaware that a gown was required upon returning to the bedside, and the LPN acknowledged noticing the lapse but did not intervene. Leadership staff, including the DON and medical director, confirmed that gowns are required for all hands-on care for residents on enhanced barrier precautions, regardless of the specific task.