Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident requiring Enhanced Barrier Precautions (EBP) to prevent the transmission of multidrug-resistant organisms (MDROs). The resident, who was moderately cognitively impaired and had an unstageable pressure injury, required substantial assistance with mobility, toileting, and hygiene. The care plan and physician orders specified the use of disposable gowns and gloves during high-contact care activities, such as dressing changes, bathing, toileting, and wound care. However, during observation, it was noted that the EBP sign had fallen to the floor, and there was no personal protective equipment (PPE), including gloves or gowns, available inside or near the resident's room. Certified Nursing Assistants (CNAs) providing incontinence care and changing linens for the resident did not wear isolation gowns, as required by the EBP protocol. Both CNAs confirmed they did not use gowns, and one was unaware that the resident was on EBP. They also reported that gowns were often not readily available throughout the facility. The lack of adherence to EBP protocols and unavailability of PPE had the potential to affect additional residents on the same floor, as staff could provide care to multiple residents during their shifts. The facility's policy required gown and glove use for high-contact care activities, but this was not followed during the observed care.