Failure to Implement Enhanced Barrier and Airborne Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policies related to enhanced barrier precautions and airborne precautions for two residents. Facility policy on Enhanced Barrier Precautions requires staff to wear gown and gloves when providing care to residents with indwelling medical devices, including feeding tubes, regardless of MDRO status. Resident R2’s record showed diagnoses including anoxic brain damage, persistent vegetative state, COPD, dysphagia following cerebral infarction, and the presence of a gastrostomy feeding tube, with a physician’s order dated January 17, 2026, for enhanced barrier precautions related to the feeding tube. On March 30, 2026, at 10:20 a.m., a nursing aide (Employee E4) was observed providing direct morning care to this resident without wearing required PPE such as a gown, and this was confirmed by the unit manager (Employee E3). The facility’s policy on Categories of Transmission-Based Precautions states that airborne precautions, in addition to standard precautions, must be implemented for residents with infections transmitted by airborne droplet nuclei, such as tuberculosis, and that these precautions are to be used when more stringent measures than standard precautions are needed. Resident R3 was placed on airborne precautions after testing positive for tuberculosis, with a physician’s order dated March 23, 2026, specifying airborne precautions for tuberculosis, including gown, face mask, face shield, and gloves. On March 30, 2026, at 10:40 a.m., a licensed nurse (Employee E5) was observed in contact with this resident in the resident’s room wearing only a mask, without the ordered gown or face shield, and this observation was confirmed by the unit manager (Employee E3). These observations demonstrated noncompliance with the facility’s own infection control policies and physician orders for both enhanced barrier and airborne precautions.
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