Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required during high-contact care activities for a resident with a weeping wound on the left foot. Despite clear signage outside the resident's room indicating the need for EBP, including the use of gowns and gloves for activities such as transferring and toileting, staff members including a nursing assistant and the director of nursing entered the room and provided care without donning the appropriate personal protective equipment. The nursing assistant only wore gloves while changing the resident's brief and pants, and the director of nursing applied a gait belt without any PPE, even though her body was in direct contact with the resident. Interviews with staff revealed a lack of understanding regarding when EBP should be used, with both the nursing assistant and the director of nursing incorrectly believing that EBP was only necessary for wound or catheter care, not for transfers or toileting. The infection preventionist and another LPN confirmed that EBP should have been used for all high-contact care activities due to the resident's wound. Review of the facility's policy and the resident's care plan further indicated that the need for EBP during high-risk care was not properly identified or communicated, contributing to the failure to follow infection control protocols.