Failure to Implement Enhanced Barrier Precautions During High-Contact Device Care
Penalty
Summary
Facility staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact resident care activities for residents on EBP. The policy specified that high-contact activities, including device care or use such as feeding tubes and urinary catheters, required the use of gown and gloves to prevent the spread of multi-drug resistant organisms. Resident #7 had an order placing the resident under EBP due to a percutaneous endoscopic gastrostomy (PEG) tube, and the care plan identified EBP for high-contact activities, including feeding tube care. During an observation of a bolus feeding via PEG tube at the bedside, an LPN administered the bolus without wearing a gown, despite later confirming that the resident was on EBP precautions due to the PEG. Resident #15 had diagnoses including urinary tract infections and hemiplegia and an order for an indwelling Foley catheter with catheter care to be provided each shift. During an observed catheter care episode, an LPN wore gloves but did not don a gown before performing the catheter care. In a subsequent interview, the DON confirmed that the LPN should have worn a gown prior to performing catheter care. These observations demonstrated that staff did not consistently implement the required EBP measures, specifically the use of gowns during high-contact care involving a PEG tube and an indwelling Foley catheter.
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