Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to its infection control practices regarding Enhanced Barrier Precautions (EBP) during tracheostomy care for a resident. The facility's policy, dated 6/11/24, mandates the use of gown and gloves for high-contact resident care activities, such as tracheostomy care, to prevent the spread of multi-drug resistant organisms. Despite this policy, an observation on 1/06/25 revealed that a registered nurse (RN) did not wear a gown while performing tracheostomy care on a resident, even though signage on the resident's door indicated the requirement for EBP and personal protective equipment (PPE) was readily available. The resident involved had a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy, with a physician's order for EBP dated 10/24/24. During an interview, the RN confirmed the omission of the gown, justifying the action by stating that additional PPE was unnecessary if the resident was not infected or had COVID. This failure to follow the established EBP policy was identified as a deficiency in the facility's infection control practices.
Plan Of Correction
Nursing Home Administrator (NHA), Director of Nursing (DON) & infection preventionist reviewed education & procedure again individually with the staff member that failed to follow policies & procedures related to Enhanced Barrier Precautions (EBP). Facility reviewed all residents under EBP and found none to be at risk. Part of our review determined all residents on EBP do have the proper PPE available. NHA & DON re-educated on EBP and how it impacts them in their roles and to follow care plan for EBP. R1 CarePlan reviewed and educated staff member individually on following policy for EBP with R1 specifically as well as all other residents under the same precautions. Director of Nursing or designee will audit proper use of EBP when providing care to 3 residents under precautions every shift time two weeks, and then 5 residents monthly for 3 months. Staff have been educated and are aware how and when to utilize PPE for EBP residents. This process will be reviewed in our QAPI (Quality Assurance Performance Improvement) plan and updated as needed based on ongoing audits.