F0880

D

Failure to Follow Enhanced Barrier Precautions During High-Contact Care

Trinity, Texas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure staff followed its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident with a chronic wound. The resident was an older adult with dysphagia, hypertension, and a history of cerebral infarction, and had severe cognitive impairment with a BIMS score of 3. The resident’s care plan, revised in November 2025, documented a stage 4 pressure ulcer on the right lateral ankle and required EBP, including gown and gloves, during high-contact care. Physician orders and the facility’s order listing confirmed an active order for EBP beginning in November 2025, and an EBP sign was posted on the resident’s door.

On the observed date, CNA A entered the resident’s room, where the EBP sign was posted, and provided incontinent care and dressing without wearing a gown, using only gloves. She dressed the resident and repositioned her in bed, then removed her gloves, discarded them, exited the room, and sanitized her hands. In a subsequent interview, CNA A stated she was unaware the resident was on EBP, did not notice the sign, and expected PPE to be available in the hallway, which it was not. She acknowledged that gown and gloves should be worn for residents on EBP during care such as dressing. The DON and Administrator both confirmed that the resident was on EBP, that gowns and gloves were required for high-contact care including dressing, and that the DON, as the Infection Preventionist, was responsible for ensuring staff were trained on infection control. The facility’s written policy on Personal Protective Equipment–Enhanced Barrier Precautions specified that gown and glove use is required during high-contact resident care activities, including dressing, for residents with chronic wounds.