F0880

D

Failure to Follow Enhanced Barrier Precautions During Therapy Sessions

Springfield, Ohio Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to ensure therapy staff followed physician orders and facility policy for Enhanced Barrier Precautions (EBP) for residents receiving therapy outside their rooms. A resident admitted with diagnoses including sepsis, multiple myeloma, congestive heart failure, and other bacterial infections had an order for EBP, and the admission MDS showed the resident was cognitively intact but required substantial to maximum assistance with transfers and bed mobility and was dependent on staff for toilet hygiene and bathing. During an observation, a Physical Therapy Assistant (PTA) provided hands-on assistance to this resident for a transfer from a wheelchair to a set of steps in a common area without wearing a gown or gloves, despite the resident being on EBP due to a wound.

In interviews, the PTA confirmed he provided hands-on assistance without donning a gown or gloves and acknowledged the resident was on EBP. An Occupational Therapist stated that therapy staff follow EBP when treating residents in their rooms but not in the therapy gym when providing hands-on assistance. The Director of Rehabilitation confirmed that therapy staff do not follow EBP when providing treatment for residents with EBP orders in the therapy gym. Review of the facility’s EBP policy showed that EBP is to be implemented to prevent transmission of multidrug-resistant organisms and that gowns and gloves should be used during high-contact care activities, including transfers and mobility assistance in shared/common areas and the therapy gym. CDC guidance reviewed by surveyors similarly described EBP as targeted gown and glove use during high-contact resident care activities and indicated EBP may be needed for residents with wounds or indwelling medical devices.