F0880

E

Failure to Follow Enhanced Barrier Precautions During Direct Resident Care

Tyler, Texas Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for three residents who had active physician orders for EBP and visible EBP signage on their doors. Each resident had a documented need for EBP: one resident had a widespread rash and other skin conditions, another had a PEG tube, and a third had other skin changes. Surveyors observed that EBP signage at the room entrances directed staff to clean hands before and after leaving the room and to wear gloves and gowns for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting, and device care including feeding tubes.

Despite these orders and posted instructions, CNAs and an LVN did not follow EBP requirements during direct care. One CNA entered a resident’s room to perform a bed bath without sanitizing her hands before entry and without donning a gown. Another CNA entered a different resident’s room to provide perineal care and likewise did not sanitize her hands before entering and did not put on a gown. Later, an LVN was observed providing enteral feeding to a resident with a PEG tube without wearing a mask or gown, even though EBP signage and PPE were present at the room entrance. In interviews, the CNAs acknowledged they failed to put on gowns despite having been trained on EBP, and the LVN stated she did not notice she had not put on a gown but was aware of the EBP requirements. The DON, who serves as the Infection Preventionist, and the Administrator acknowledged that staff had been trained and retrained on EBP and stated that such failures could place residents at risk for cross contamination, spread of infection, and sepsis.