Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow Enhanced Barrier Precautions (EBP) during the care of a resident who was admitted with diagnoses including a pressure ulcer, chronic diastolic heart failure, atrial fibrillation, and hypertension. The resident's room was clearly marked as requiring EBP due to the presence of a pressure ulcer, which necessitates targeted use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Despite this, the RN entered the resident's room multiple times to perform direct care activities, including checking blood pressure and pulse, administering medications, and removing and applying a Lidocaine patch, all without donning the required PPE. The RN acknowledged during an interview that the room was designated for EBP because of the resident's pressure ulcer but admitted to not using PPE while performing these care tasks. Facility policy specifies that EBP is intended to prevent the spread of multi-drug resistant organisms (MDROs) during high-contact activities involving resident care, equipment, or skin. The failure to consistently implement EBP as outlined in facility policy was directly observed and confirmed through staff interview and record review.