Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during care of a resident who was on EBP due to a tracheostomy and gastrostomy tube. The LVN performed a dressing change at the tracheostomy site and disconnected a feeding tube without donning a gown or performing hand hygiene prior to these high-contact tasks. The LVN acknowledged not following the required infection control practices, despite the presence of signage indicating EBP requirements and her awareness of the necessity for gown use and hand hygiene. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene and device care. Facility records confirmed that EBP precautions were ordered for the resident, and the infection prevention nurse and director of nursing both stated that staff are required to use gowns and perform hand hygiene for high-contact care tasks under EBP. The facility's policy specified that PPE, including gowns and gloves, must be donned before each high-contact task and that adherence to infection prevention practices should be periodically monitored.