Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for residents on enhanced barrier precautions (EBP). Specifically, staff did not adhere to required personal protective equipment (PPE) protocols when providing care to residents with indwelling devices and open wounds. Observations revealed that a registered nurse and two licensed vocational nurses entered the rooms of residents on EBP and performed high-contact care activities, such as disconnecting and flushing an IV line, checking blood pressure, and providing gastrostomy tube care, without wearing the mandated mask, gloves, and gown. Resident 2, who was admitted with diagnoses including acute osteomyelitis, dysphagia, and a chronic ulcer, was on EBP due to wounds and a midline catheter. Despite clear signage and availability of PPE outside the resident's room, staff were observed entering and providing care without donning the required protective equipment. Interviews with the involved staff confirmed that they were aware of the EBP requirements but failed to comply, citing reasons such as forgetting to wear a mask or not noticing the available supplies. The Director of Nursing and Infection Preventionist both acknowledged that the staff should have worn the appropriate PPE during these care activities. Similarly, Resident 6, who had a gastrostomy tube and required maximum assistance for activities of daily living, was also on EBP. An LVN was observed providing gastrostomy tube care at the bedside without wearing a gown, despite the presence of EBP signage and PPE supplies. The LVN admitted awareness of the EBP requirement but did not comply. Facility policies and local health orders reviewed by surveyors confirmed the necessity of PPE use during high-contact care and during respiratory virus season, yet these protocols were not followed during the observed incidents.