Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow established infection prevention and control protocols during incontinent care for a resident on Enhanced Barrier Precautions (EBP). The CNA entered the resident's room, which had EBP signage and available personal protective equipment (PPE), and performed incontinent care wearing only gloves but not a gown as required. During the care, the CNA did not change gloves or perform hand hygiene when transitioning from a contaminated to a clean area, contrary to facility policy and the resident's care plan. The CNA later acknowledged understanding the requirements but stated she forgot to wear a gown and to change gloves due to nervousness. The resident involved was an older male with multiple comorbidities, including heart failure, hypertension, diabetes mellitus, and a history of cerebrovascular accident, and was completely dependent on staff for incontinent care. His care plan specified the use of gloves and gowns during high-contact care activities due to the presence of indwelling medical devices and wounds, and to reduce the risk of infection. Facility policies reviewed confirmed the necessity of donning both gown and gloves for such care and performing hand hygiene when moving from dirty to clean tasks. Interviews with facility leadership confirmed these expectations for staff.