Failure to Implement Enhanced Barrier Precautions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included the necessary Enhanced Barrier Precautions (EBP) for infection control. The resident, a male with a history of arterial ulcers and methicillin-resistant Staphylococcus aureus infection, was admitted with a draining wound on the right foot. Despite physician orders indicating the need for EBP due to the open wound, the care plan did not reflect this requirement, leading to a lack of proper signage and personal protective equipment (PPE) availability in the resident's room. Observations revealed that staff members, including CNAs and an LVN, were unaware of the resident's EBP status, as there was no signage or PPE supply cart present. During a transfer after bathing, staff did not wear PPE gowns, indicating a gap in communication and implementation of the necessary precautions. Interviews with staff, including the DON and MDS nurse, confirmed the oversight, with the MDS nurse admitting to forgetting to include EBP in the care plan. The facility's policy on comprehensive person-centered care plans emphasizes the inclusion of measurable objectives and timeframes to meet residents' needs, yet this was not adhered to in the case of the resident. The lack of EBP in the care plan and the absence of proper signage and PPE could lead to confusion among staff and potentially expose the resident to infection, as noted by the DON.