Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection control policy for a resident who was on enhanced barrier precautions (EBP) due to multiple chronic wounds and a history of cerebrovascular accident with left side weakness and reduced mobility. According to the resident's care plan, EBP, including the use of gowns and gloves during high-contact care activities, was required to reduce the risk of transmission of multidrug-resistant organisms (MDROs). The resident was dependent on staff for most activities of daily living, including bed mobility and hygiene. On the observed date, a certified nurse assistant (CNA) entered the resident's room wearing gloves but did not don a protective gown while repositioning the resident in bed, an activity classified as high-contact care. The CNA stated during an interview that he was unaware the resident was on EBP. Facility policy, as reviewed, required both gloves and gowns to be used during such activities for residents on EBP. The Director of Staff Development confirmed that the resident was on EBP and that staff should have used the appropriate personal protective equipment during repositioning.