Failure to Follow Enhanced Barrier Precautions During Oral Care
Penalty
Summary
Nurse Aide #3 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing oral care to Resident #2, who was under EBP due to wounds and an indwelling catheter. During an observation, NA #3 entered the resident's room, draped a blanket over the resident, and began providing oral care while wearing only a mask and gloves, omitting the required gown. The EBP signage was clearly posted outside the room, indicating the need for gown and gloves during high contact care activities such as providing hygiene. NA #3 acknowledged awareness of the policy and attributed the lapse to rushing, despite having received training on EBP procedures. Resident #2 was in a semi-private room, and both occupants were on EBP. The facility's policy, dated 5/13/2023, specified that gown and gloves must be used for high contact care activities for residents with wounds or indwelling medical devices. Interviews with the DON and Administrator confirmed that staff were expected to don appropriate PPE, including gowns and gloves, when performing hands-on care for residents on EBP. The deficiency was identified during direct observation and confirmed through staff interviews, highlighting a failure to implement the facility's infection control policy during a high contact care activity.