Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident receiving dialysis, which could lead to cross-contamination among vulnerable residents. The resident, identified as R12, was admitted with end-stage renal disease and was receiving dialysis. Despite the resident's care plan and physician orders indicating the need for monitoring and reporting signs of infection, there was no order for EBP, and no signage or personal protective equipment (PPE) was available outside the resident's room. Observations and interviews revealed that staff did not use gowns when providing care to R12, and there was a lack of understanding among staff about the necessity of EBP for dialysis patients. The Director of Nursing and other staff members believed that EBP was not required according to CDC guidelines, despite the facility's policy indicating that residents with indwelling medical devices should be under EBP. This oversight in implementing EBP for R12, who had a dialysis shunt accessed multiple times a week, was a deficiency in infection prevention and control measures.
Plan Of Correction
NJ Ex Order 26.4(b)(1) per facility policy was initiated on 12/5/24 for Resident 12. All dialysis residents with access sites are potentially affected. All staff were inserviced by Infection Preventionist Nurse to ensure all dialysis residents with access sites have enhanced barrier precautions per facility policy. All dialysis residents with access sites will be placed on enhanced barrier precautions per facility policy. Unit Manager and/or designee will be responsible to assure residents with dialysis access sites are identified and have physicians order for enhanced barrier precautions on admission and with status changes. Infection Preventionist and/or designee will make rounds weekly on dialysis patients to assure compliance with enhanced barrier precautions. Results of these audits will be reported to the Administrator on a monthly basis. The Infection Preventionist will report the results of these audits quarterly during the QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.