Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the case of one resident with an indwelling urinary catheter and an order for enhanced barrier precautions (EBP). On the date of observation, a CNA provided incontinent care to this resident without wearing a gown, despite clear signage outside the resident's room indicating the need for EBP and a physician's order specifying the use of gown and gloves for high-contact care activities. There was no evidence of a used gown in the trash, and the CNA confirmed during interview that she had forgotten to wear the required gown while providing care. The resident involved had severe cognitive impairment and was dependent on staff for care, with medical records reflecting the presence of an indwelling catheter and a care plan intervention for EBP. Facility policy required the use of gown and gloves for residents with indwelling medical devices during high-contact care. Interviews with the DON, ADON, and Administrator confirmed that staff were expected to follow EBP protocols, and that the CNA's failure to wear a gown during care was not in compliance with facility policy and physician orders.