Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and CDC, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and surgical wounds. The facility's policy, dated August 28, 2024, required EBP for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization. However, during observations on January 7 and 8, 2025, it was noted that there was no signage on or outside the resident's room to indicate the need for EBP, despite the resident having an indwelling catheter and unhealed surgical wounds. The resident in question, identified as Resident 50, had mild cognitive impairment, was dependent on assistance for mobility, and had multiple medical conditions, including two Stage 2 pressure ulcers and a surgical wound with infection. The resident's care plan included EBP for both the surgical wound and the indwelling catheter. Despite these documented needs, the facility did not display the required signage to alert staff and visitors of the necessary precautions, as confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. The identified concern for R50 was immediately corrected. 2. The Director of Nursing or designee will audit all residents to ensure that appropriate enhanced barrier precaution (EBP) signage is present for the affected residents. 3. The Director of Nursing or designee will re-educate all staff on appropriate placement of enhanced barrier precaution (EBP) signage. Education will include when residents require enhanced barrier precautions that signage is put in place in addition to appropriate personal protective equipment (PPE). 4. The Director of Nursing or designee will audit residents to ensure that appropriate enhanced barrier precaution (EBP) signage is present outside the room in addition to appropriate PPE of the affected residents weekly x4 then monthly x2. All findings will be submitted to the Quality Assurance Committee.