Failure to Follow Enhanced Barrier Precautions for Resident With Feeding Tube
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling medical device. The facility’s EBP policy, last reviewed November 14, 2025, required the use of protective gowns during high-risk activities for any resident with an indwelling medical device when contact was expected, and staff were to be trained on what constituted high-risk activity. Resident 113 had diagnoses including stroke and dysphagia and had a gastrostomy tube in place. The Minimum Data Set dated November 3, 2025, documented significant cognitive impairment and the presence of a feeding tube. The resident’s care plan directed staff to follow EBP when providing personal care and when handling the feeding tube, and a sign posted outside the resident’s room instructed staff to use EBP, including gowns, during high-contact direct care such as hygiene and feeding tube device care. On January 27, 2026, at 10:30 a.m., an LPN was observed sitting on Resident 113’s bed without wearing a protective gown while providing care to the resident’s feeding tube, despite the posted EBP sign. From 10:31 a.m. to 10:41 a.m. that same day, the same LPN and a nurse aide provided hygiene care to Resident 113 without wearing gowns. The nurse aide later confirmed in an interview that hygiene care was being provided during that time. In a subsequent interview on January 29, 2026, the Director of Nursing stated that staff should have worn gowns when providing care to Resident 113, confirming that the observed practice did not comply with the facility’s EBP policy and the resident’s care plan.
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