Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) while providing direct care to a resident with multiple complex medical conditions, including a gastrostomy tube, end stage renal disease, and severe cognitive impairment. The resident was under physician orders for EBP, which required staff to don a disposable gown and gloves when providing care. On the observed date, signage indicating EBP requirements was posted on the resident's door, and personal protective equipment (PPE) was available at the entrance. Despite these measures, the CNA admitted to not wearing a disposable gown while performing incontinent care for the resident, stating she was in a hurry to prepare the resident for dialysis. The facility's Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist, confirmed that all staff were expected to use gloves and gowns when providing care to residents with devices such as gastrostomy tubes. The ADON acknowledged that failure to don appropriate PPE during care increased the risk of cross-contamination. Review of the facility's infection prevention and control policy indicated that the facility was required to maintain an infection control program in accordance with national standards, which was not followed in this instance.