Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered Enhanced Barrier Precautions (EBP) for a resident requiring infection control measures. The resident’s clinical record showed diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, vascular dementia, and intellectual disability. A physician’s order dated 3/8/26 directed staff to utilize EBP during high-contact resident care activities every shift related to a gastrostomy tube, and a care plan dated 3/9/26 documented that the resident required EBP. Facility signage on the resident’s door instructed that everyone must cleanse their hands before entering and when leaving the room, and that providers and staff must wear gloves and a gown for specified high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, and device care including feeding tubes. On observation, a CNA provided incontinence care to the resident without following the EBP requirements. The CNA donned gloves but did not put on a gown while changing the resident’s urine-soaked brief, wet shirt, wet bed sheets, and wet pants. The urine-soaked bed sheet came into contact with the CNA’s uniform. After changing some linens, the CNA left the room carrying a dirty bag of linens while still wearing the same gloves, then re-entered the room with the same gloves and continued providing care, without changing gloves or wearing a gown at any time. In an interview, the CNA stated he usually wore a gown for care but forgot and acknowledged he should have worn one. Another CNA confirmed that staff should wear a gown and gloves when completing ADL care for a resident on EBP. The facility’s written policy on Contact Precautions, including EBP, specified that gown and glove use is required during high-contact resident care activities such as providing hygiene, changing linens, and changing briefs or assisting with toileting.
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