Failure to Follow Enhanced Barrier Precautions During Transfer and Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure enhanced barrier precautions (EBP) were followed during transfer and perineal care for a resident on EBP due to a history of multidrug-resistant organisms (MDRO). The resident had diagnoses including age-related physical debility, Alzheimer’s disease, delusional disorders, and dementia with behavioral disturbances, and was severely impaired in decision-making. She was dependent on staff for toileting hygiene, lower body dressing, and transfers, and was always incontinent of bowel and bladder. Her care plan documented a history of MDRO Proteus mirabilis and ESBL in her urine, with an order for EBP in place and an intervention that staff and visitors would follow EBP. During an observation, two CNAs entered the resident’s room, where an orange EBP magnet was posted on the doorframe, and used a mechanical lift to transfer her into bed. They wore gloves but did not don gowns at any time during the transfer or while providing perineal incontinence care, despite the resident’s EBP status. As they rolled the resident from side to side to complete perineal care, the resident’s right arm and hand came into contact with the front of each CNA’s uniform. Both CNAs later acknowledged they should have worn gowns for the transfer and incontinence care, and the DON confirmed gowns were required for these high-contact care activities under the facility’s EBP policy, which lists dressing, transferring, and changing briefs as high-contact resident care activities requiring targeted gown and glove use.
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