Failure to Follow Enhanced Barrier Precautions During G Tube Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for a resident who was on enhanced barrier precautions (EBP) due to the presence of a wound and a gastrostomy (G) tube. According to the resident's medical records, the resident was dependent on staff for all activities of daily living and had severe cognitive impairment. Physician orders and facility policy required staff to wear both gloves and a gown when providing direct care, including G tube care, to prevent the spread of multi-drug-resistant organisms (MDROs). During an observation, a Licensed Vocational Nurse (LVN) entered the resident's room, which had EBP signage posted, and provided G tube care while wearing gloves but without donning a gown. The LVN stated she intended to loosen the G tube before putting on the gown but acknowledged she should have worn the gown before providing care. Both the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the LVN should have worn a gown during the procedure, as required by facility policy and the resident's care plan.