F0880

E

Failure to Implement Enhanced Barrier Precautions During High-Contact Care

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for all seven observed residents on the ventilator unit. The facility’s EBP policy, dated 3/25/24, requires targeted use of gown and gloves during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, device care (including feeding tubes and tracheostomies/ventilators), and wound care. Despite posted EBP signage and availability of PPE carts at many room doors, staff repeatedly performed high-contact care activities wearing only gloves or, at times, no PPE other than a mask, contrary to the policy requirements.

For one resident with ALS who is ventilator-dependent with a tracheostomy and feeding tube, an LPN administered medications via the feeding tube while wearing only a mask and gloves, without a gown, even though the resident was on EBP and had an EBP sign posted on the door. Later, a CNA provided personal care to the same resident, including changing soiled bedding and handling soiled linens, while wearing gloves but no gown, despite a PPE container being present on the door. The CNA also left the room wearing the same gloves to obtain clean linens from the clean linen cart before returning to the room and closing the door.

For another resident with chronic respiratory failure, a feeding tube, tracheostomy, and ventilator, an LPN performed suctioning while wearing only a mask and gloves, without a gown, even though an EBP sign was posted outside the room. During therapy for this same resident, a PTA and a CNA entered the room wearing only gloves and no gowns while assisting the resident to sit on the edge of the bed and providing therapy. For a third resident with anoxic brain damage, respiratory failure, dysphagia, a feeding tube, indwelling urinary catheter, tracheostomy, and ventilator, a CNA entered the room, which had both EBP and contact isolation signs posted, and repositioned the resident in bed by removing bedding and adjusting pillows without wearing gloves or a gown, and without closing the door.

Another resident with chronic respiratory failure, dysphagia, anxiety disorder, encephalopathy, a gastrostomy tube, tracheostomy, and ventilator had a PPE container on the door but no EBP sign posted. Staff, including a CNA, PTA, and RT, transferred this resident from a Broda chair to bed using a Hoyer lift while wearing only gloves and no gowns. For a resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, a feeding tube, and tracheostomy, a CNA performed extensive incontinence care and hygiene, including washing the resident’s body, cleaning bowel movement from the perineal and buttock areas, changing soiled draw sheets, and restarting tube feeding, while wearing only gloves and no gown. A second CNA who assisted with repositioning and changing soiled linens also wore only gloves and no gown during this high-contact care.

For a resident with chronic respiratory failure, encephalopathy, dysphagia, a feeding tube, and tracheostomy, a CNA prepared to provide incontinence care by moving a linen cart to the room and entering with gloves only, without donning a gown, despite an EBP sign and PPE cart outside the room. For another resident with myotonic muscular dystrophy, chronic respiratory failure with hypoxia, dysphagia, anxiety disorder, a feeding tube, tracheostomy, and ventilator, a CNA performed full incontinence care and linen changes while the resident’s incontinence product was saturated with urine and there was a large amount of stool present. The CNA cleaned the resident’s perineal and rectal areas, changed soiled sheets, applied barrier cream, and replaced the incontinence product, all while wearing gloves but no gown, even though an EBP sign and PPE container were posted outside the room. In an interview, the ADON stated that staff identify residents on EBP or isolation by signs outside the door and described that gowns should be worn for activities such as brushing teeth, grooming, bathing, dressing, incontinence care, and transferring, but the observations showed staff not wearing gowns during these high-contact care activities.