Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP). Resident #17 was admitted on 03/11/25 with diagnoses including acute respiratory failure, depression, anxiety, a history of infectious and parasitic diseases, and gastrostomy status. A Minimum Data Set (MDS) assessment dated 12/16/25 documented that the resident had severe cognitive deficits, required substantial assistance with activities of daily living, and was incontinent of bowel and bladder. Physician orders dated 03/12/25 directed that the resident be placed on EBP related to the gastrostomy tube and tracheostomy. On 03/02/26 at 1:18 P.M., surveyors observed two CNAs providing incontinence care to Resident #17 without wearing gowns, despite the resident being on EBP. Both CNAs confirmed during interviews that they had not worn gowns while providing this care and acknowledged that they should have worn gowns because the resident was on EBP. Review of the facility’s Enhanced Barrier Precautions policy dated 05/2024 showed that EBP is an infection control intervention using targeted gown and glove use during high-contact resident care activities, which include changing briefs, assisting with toileting, providing hygiene, and device care such as feeding tubes and tracheostomy tubes. The observed incontinence care fell under these high-contact activities, but the required gown use was not followed.
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