Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident undergoing dialysis, identified as Resident #7. The facility's policy required EBPs for residents with indwelling medical devices, such as an arteriovenous fistula, to prevent the transmission of multi-drug-resistant organisms. Despite this requirement, Resident #7, who had a fistula and was receiving hemodialysis, was not placed on EBP. Observations and interviews revealed that staff did not wear gowns when checking the resident's dialysis access site, and there were no EBP postings outside the resident's room. Interviews with facility staff, including a Licensed Vocational Nurse, the Unit Manager, the Infection Preventionist, the Director of Nursing, and the Executive Director, confirmed that Resident #7 met the criteria for EBP but was not included in the program. The Infection Preventionist acknowledged the oversight, and the Director of Nursing stated that the facility's expectation was for the Infection Preventionist to recognize and implement EBP immediately when required. The Executive Director also confirmed that the resident should have been on EBP to ensure safety protocols were followed.