Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with a wound and indwelling medical devices. The resident in question had a history of frequent urinary tract infections, an indwelling Foley catheter, a feeding tube (G-tube), and a stage 2 pressure ulcer. The care plan and physician orders did not document the need for EBP, despite the resident's risk factors. Staff interviews confirmed that EBP training had been provided, and signage and personal protective equipment (PPE) were available near the resident's room. During direct observation, a nurse and a CNA entered the resident's room, failed to wash their hands, and did not don gowns or gloves before providing direct care, which included turning the resident and checking for skin breakdown. Both staff members acknowledged after the fact that they had been trained on EBP but failed to follow the protocol due to nervousness and being rushed. The CNA incorrectly believed EBP was no longer necessary because the resident's catheter had been discontinued, although the resident still had a G-tube and a pressure ulcer, which required continued EBP according to facility policy. Interviews with additional staff, including the DON and RN, confirmed that EBP should be followed for residents with indwelling medical devices or wounds during high-contact care activities. The facility's policy, effective as of April 2024, clearly outlined the requirements for EBP, including the use of gowns and gloves during specific care activities. Despite this, the observed failure to implement EBP placed the resident at risk for cross-contamination and the potential spread of infections.