F0880

D

Failure to Follow Enhanced Barrier Precautions During Incontinent Care

Washington, District Of Columbia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy when providing high-contact care to a resident on EBP. The facility’s EBP policy, revised on 06/26/25, defines EBP as an infection control intervention using targeted gown and glove use during high-contact resident care activities, including providing hygiene and changing briefs. The policy states that all staff are trained on EBP upon hire and at least annually and are expected to comply, and that PPE for EBP is required during high-contact care activities. Signage on the resident’s door indicated the resident was on EBP and directed staff performing any high-contact care activity to don gloves, a mask, and a gown before entering the room. A storage bag with gloves, masks, and gowns was hanging on the resident’s door.

The resident involved was admitted with multiple diagnoses, including MRSA infection, complications of colostomy, hidradenitis suppurativa, protein calorie malnutrition, and a need for assistance with personal care, and had multiple physician orders for barrier creams, colostomy care, urinary fistula care, and wound care to the groin areas. During an observation, the resident requested a brief change, and a CNA responded, washed hands, and donned gloves but did not don a gown before entering the room and performing incontinent care and applying cream. After completing care, the CNA removed gloves and washed hands before exiting. In a face-to-face interview, the CNA acknowledged the resident was on EBP due to a colostomy and wounds and stated he did not know why he had not put on a gown, saying he “just forgot,” thereby confirming noncompliance with the facility’s EBP policy during a high-contact care activity.