Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident on EBP and two CNAs providing care. The resident was an adult female with Down syndrome, severe cognitive impairment (BIMS score of 3/15), generalized muscle weakness, gait and mobility abnormalities, type 2 diabetes mellitus with unspecified complications, and a documented ADL self-care deficit requiring total dependence with two-person transfers between bed and wheelchair. On the observation date, an EBP sign was posted on the resident’s door, indicating that enhanced barrier precautions were required during high-contact care activities such as transferring. Surveyors observed that one CNA entered the resident’s room with a mechanical lift and did not don any PPE before entering, and a second CNA entered to assist with the transfer and donned only clean gloves without a gown, despite the transfer being a high-contact care activity under the facility’s EBP policy. The resident was then transferred from bed to wheelchair via mechanical lift without both CNAs wearing the required gown and gloves. In subsequent interviews, both CNAs acknowledged they had received in-services on PPE use to prevent infection but stated they had forgotten to wear the required PPE during the transfer. The Administrator stated that his expectation was that staff don PPE before entering the rooms of residents with EBP signage to perform any care, consistent with the facility’s written EBP policy, which requires gown and glove use for high-contact activities such as transferring.
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