Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow the facility's Enhanced Barrier Precautions (EBP) protocol while providing care to a resident with a history of type 2 diabetes mellitus and a foot ulcer. During an observed transfer using a mechanical lift, two CNAs did not wear gowns as required by the facility's EBP policy, despite signage and PPE supplies being present outside the resident's room. The resident's care plan indicated the need for EBP due to actual skin impairment and incontinence, and the facility's policy specified that gowns and gloves must be worn during high-contact activities such as transfers. Interviews with the CNAs and facility leadership confirmed that staff were aware of the EBP requirements, but the CNAs believed gowns were only necessary for certain types of care, not transfers. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both stated that the expectation was for staff to don gowns and gloves during transfers for residents on EBP. The facility's policy, dated 4/1/2024, clearly outlined the need for PPE during such activities, but this was not followed during the observed incident.