Failure to Follow Enhanced Barrier Precautions During Bathing of PEG Tube Resident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) requirements for personal protective equipment (PPE) while providing care to a resident with a PEG tube. The facility’s EBP policy, revised 11/13/25, specified that gown and gloves must be used for high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care or use of a PEG tube. An EBP sign posted outside the resident’s room directed that everyone must clean their hands before entering and when leaving, and that providers and staff must wear gloves and a gown for high-contact activities such as bathing and PEG tube care. During an observation, two nurse aides were seen in the resident’s room providing a bed bath without adhering to the required PPE. Neither aide was wearing a gown, and only one aide was wearing gloves, despite both acknowledging awareness of the EBP sign on the door. One aide stated she typically only wore a gown when working with the resident’s external urine collection device, though she recognized that bathing was a task requiring EBP and that gowns should have been worn. The other aide agreed that gowns and gloves were required for bathing this resident. The DON, who also served as the Infection Preventionist, and the Administrator both confirmed in interviews that the aides should have followed the EBP sign and worn at least gloves and a gown prior to bathing the resident, and that staff had received EBP training during orientation and annual competency training.
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