Failure to Follow Enhanced Barrier Precautions During Tube Feeding Care
Penalty
Summary
A deficiency was identified when a Registered Nurse (RN) failed to wear the required Personal Protective Equipment (PPE), specifically a gown, while providing care to a resident on Enhanced Barrier Precautions (EBP). The RN entered the resident's room to flush and disconnect a feeding tube without donning a gown, despite facility policy and CDC guidance requiring gown and gloves for high-contact care activities such as tube feeding. The Certified Nursing Assistant (CNA) was observed entering the same room with the appropriate PPE, and both staff members confirmed the resident was on EBP due to the presence of a feeding tube. The resident involved had a history of cerebral infarction, aphasia, and dysphagia, and was assessed as having severely impaired cognitive skills. Facility documentation, including the resident's Plan of Care and the policy on Enhanced Barrier Precautions, specified the need for PPE during high-contact care. The RN acknowledged not following the protocol, while the CNA demonstrated compliance. The facility's policy outlined the importance of PPE use to prevent the spread of multidrug-resistant organisms, but this protocol was not consistently followed during the observed care.