Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not following enhanced barrier precautions (EBP) for a resident on EBP. On 02/22/26, a sign posted on the door of Resident #10’s room indicated that the resident was on EBP, requiring targeted gown and glove use during high-contact resident care activities. On 02/24/26 at 1:27 pm, during observation of Resident #10’s tube feeding, LPN #1 accessed the resident’s feeding tube while wearing gloves but did not don the required gown as specified by the EBP signage. During an interview at that time, LPN #1 stated he was not required to wear a gown when accessing the feeding tube. In a second interview at 1:35 pm the same day, LPN #1 stated he had reviewed the EBP sign on the door and realized he should have been wearing a gown. On 02/26/26 at 3:45 pm, the DON stated that tube feedings require proper personal protective equipment and that the observed practice did not meet her expectations. The report notes that this failure to utilize EBP when performing personal care for Resident #10, one of two residents reviewed for EBP, has the potential to spread organisms, diseases, and other health conditions among residents.
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