Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
Nurse #4 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact care for a resident with a tracheostomy. The EBP policy, dated 4/24/24, requires staff to don gloves and gowns prior to performing high-contact resident care activities, such as tracheostomy care, to reduce the spread of multi-drug-resistant organisms (MDROs). During an observation, Nurse #4 performed hand hygiene and donned gloves but did not wear a gown while providing tracheostomy care and suctioning to the resident, despite clear signage and available personal protective equipment (PPE) at the resident's door indicating the requirement for both gloves and gowns. Upon interview, Nurse #4 stated she did not wear a gown because she believed EBP was only necessary for incontinence care, and only realized the requirement after reading the posted EBP sign. The Infection Preventionist, Director of Nursing, and Administrator all confirmed that Nurse #4 should have worn a gown in addition to gloves during the procedure, as per facility policy. The Medical Director noted that the respiratory tract is not a sterile space and did not believe the resident was put at risk, but acknowledged the policy was not followed.