Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for two residents who required them. According to the facility's policy, EBP is an infection control intervention designed to reduce the transmission of Multidrug Resistant Organisms (MDROs) by employing targeted gown and glove use during high-contact resident care activities. The policy mandates that EBP should be implemented for residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and for those with an infection or colonization with an MDRO when contact precautions do not otherwise apply. Clinical record reviews revealed that both residents had unstageable sacrum pressure ulcers, with one resident also having a percutaneous endoscopic gastrostomy (PEG) tube. Observations of their rooms showed a lack of EBP signage or communication, indicating that the necessary precautions were not being followed. The Director of Nursing and the Nursing Home Administrator confirmed that the EBP process was not adhered to for these residents, highlighting a deficiency in the facility's infection prevention and control program.
Plan Of Correction
POC- complaint survey 3/20/25 1. No residents were affected by the practice. 2. DON/designee will audit facility to determine which residents could be potentially affected. 3. DON/ADON will educate staff on EBP and EBP Policy will be posted at nursing station. 4. ADON/designee will round daily for four weeks then weekly thereafter to ensure enhance barrier precaution signs are hung and visible where necessary. Any findings will be presented in QAPI. 5. Corrective action will be completed by 4/4/2025.