Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 and Treatment Nurse (TN) 1 failed to follow the facility's infection control protocols by not wearing an isolation gown while providing direct contact care to a resident who was on Enhanced Barrier Precautions (EBP). The resident had a suprapubic stoma for intermittent catheterization and pressure injuries on the left ischium and right heel, conditions that placed them at higher risk for multidrug resistant organisms (MDROs). During wound care, bed bathing, and brief changing, both CNA 1 and TN 1 provided high-contact care without donning the required isolation gown, despite signage at the resident's doorway and facility policy indicating the necessity of gown and glove use for such activities. Interviews with CNA 1 and TN 1 revealed that both staff members acknowledged forgetting to wear the gown during the high-contact care activities, and recognized that this was contrary to facility policy and infection control standards. The Director of Nurses (DON) confirmed that the resident was on EBP due to their medical conditions and that staff were required to wear gowns during high-contact care, such as bathing, changing briefs, and wound care. Review of the facility's infection prevention and control policy further supported that gown and glove use was mandatory for residents on EBP during these types of care activities.