Failure to Implement Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program, specifically regarding the implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices. According to CDC guidance, EBP requires the use of gowns and gloves during high-contact resident care activities for residents with wounds or indwelling devices, regardless of known colonization with multidrug-resistant organisms (MDROs). The facility's policy addressed standard transmission-based precautions but did not mention or address EBP, despite signage indicating EBP requirements on a resident's door. During observations, a registered nurse (RN) was seen performing a peripherally inserted central catheter (PICC) line dressing change for a resident who was admitted for antibiotic treatment and IV management. The RN wore gloves and a mask but failed to don a protective gown as required by EBP. Additionally, a certified nurse aide (CNA) assisted the same resident with transferring and incontinence care but did not wear a gown, only gloves, despite the resident being on EBP due to the presence of an IV line. Interviews with the involved staff revealed a lack of understanding and adherence to EBP protocols. The CNA believed that only gloves were necessary for personal care and did not recognize the need for a gown when assisting with transfers or incontinence care for a resident with an indwelling device. The RN acknowledged forgetting to wear a gown during the dressing change. The infection preventionist confirmed that both staff members should have used gowns and gloves for these high-contact activities, as required by EBP.