F0880

E

Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care

Concord, North Carolina Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents with certain devices or chronic wounds. For a resident with a feeding tube, an RN administered medications via the feeding tube without wearing a gown, despite an EBP sign posted at the doorway and PPE available across the hall. The nurse used hand sanitizer and gloves but omitted the gown, later acknowledging awareness that the resident was on EBP and that the sign referenced gowns and gloves for high-contact care involving a feeding tube. The Infection Preventionist and Director of Nursing both stated that a gown and gloves should have been worn for this care.

Another deficiency occurred with a resident who had a PICC line and was receiving IV antibiotics for endocarditis. During a transfer from wheelchair to bed using a mechanical lift, two nurses and a nurse aide entered the room and completed the transfer wearing only gloves and no gowns. They assisted the resident with rolling and removed the lift pad without donning gowns. There was no EBP signage posted inside or outside the resident’s room, even though the resident had a PICC line in place. One nurse reported she normally wore a gown and gloves for PICC-related care but was not prompted to don a gown for the transfer because there was no EBP sign. The Infection Preventionist later stated that the resident should have been placed on EBP due to the PICC line and that she had overlooked obtaining the order and posting the signage.

A further deficiency was identified with a resident who had open wounds on the sacrum, infections, and a central line used for IV antibiotics. An NA entered this resident’s room, which had an EBP sign posted and PPE available outside the door, carrying only gloves and not wearing a gown. The NA provided care in the room, moved around the bed, accessed the closet, and exited the room still wearing gloves and carrying a trash bag, all without donning a gown. The NA stated she knew the resident was on EBP due to open wounds and infections but believed a gown was only required for dressing changes. The Infection Preventionist and DON stated that, due to the resident’s open wounds, infections, and central line, the NA should have worn both gown and gloves when providing high-contact care.

Across these events, five staff members (three nurses and two nurse aides) did not follow the facility’s EBP policy, which defined high-contact activities as including dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (including central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters), and wound care for chronic wounds or those with MDRO. The failures included not donning gowns during high-contact care for residents with a feeding tube, a PICC line, and chronic pressure ulcers with a central line, as well as the failure to identify and place a resident with a PICC line on EBP and post appropriate signage.

The Administrator stated that he expected all staff members to use the appropriate PPE according to the enhanced barrier signs posted for each resident and to wear the required PPE when providing care to residents on EBP. However, the observations and interviews documented that staff either misinterpreted the EBP signage, relied solely on signage that was missing, or misunderstood when gowns were required, resulting in noncompliance with the facility’s infection control policy for EBP.