Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s Enhanced Barrier Precautions (EBP) and infection control policies during incontinence care for one resident. On 1/17/2025 at 3:45 PM, a CNA (V7) was observed exiting and re-entering the resident’s room and walking down the hallway while wearing contaminated gloves, then going to the linen cart to obtain a facecloth without removing the gloves. V7 then returned to the resident’s room and performed incontinence care without wearing a gown, despite an EBP sign posted on the resident’s door stating that staff must wear both gown and gloves for high-contact resident care activities such as changing briefs or assisting with toileting. During this care, the privacy curtain was not pulled, the room door remained open, and a soiled brief was observed on the floor next to the resident’s bed. In subsequent interviews, V7 acknowledged that the resident was on EBP and stated she should not have been wearing gloves in the hallway. An LPN (V8) confirmed that the resident was on EBP and stated that to prevent the spread of infection, staff should wear a gown and gloves during care and that soiled linen and incontinent products should not be thrown on the floor but placed in a bag and disposed of properly. Another LPN (V9) and the DON (V2) both stated that staff should wear gown and gloves when performing incontinence care for residents on EBP and that soiled linen and incontinent products should be bagged and disposed of properly. The resident involved was cognitively intact, with diagnoses including Type 2 diabetes mellitus with foot ulcer, unspecified kidney failure, dependence on renal dialysis, and acquired absence of the right leg above the knee. The facility’s EBP policy required gowns and gloves for high-contact care activities, and the Infection Control Policy required all personnel to adhere to the Infection Control Program in their daily assignments.
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