Failure to Follow Enhanced Barrier Precautions for Device Care
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring use of gowns and gloves during high-contact resident care activities involving medical devices. The facility’s EBP policy, revised on 3/26/2024, specified that gowns and gloves must be used for high-contact activities such as device care, including feeding tubes and tracheostomy care, when residents are on EBP. For one resident with a feeding tube, an EBP sign and PPE bin were posted outside the room. A nurse entered the room without a gown, performed gastric tube care by stopping the feeding pump, flushing the feeding tube with a syringe, and later reconnecting the tube to the pump, wearing only gloves. The nurse acknowledged awareness that the resident was on EBP but stated she believed a gown was only required for residents on contact precautions. In a separate incident, a nurse aide provided tracheostomy care to another resident who also had an EBP sign posted outside the room instructing staff to wear a gown and gloves, with PPE available in a bin outside the door. The nurse aide was observed cleaning around the resident’s trach using gloves and gauze but did not wear a gown. When interviewed immediately afterward, the nurse aide stated she knew she should have worn a gown while providing trach care but did not plan to be in the room long. The Infection Preventionist reported that appropriate precaution signs and PPE availability were monitored daily and that staff received training on PPE use during orientation and monthly staff meetings, and the DON stated she expected staff to use PPE according to posted precaution signs.
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