Failure to Implement Enhanced Barrier Precautions for Resident with ESBL
Penalty
Summary
The facility failed to implement its infection prevention and control program (IPCP) for a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) resistance in the urine. Despite a physician's order for Enhanced Barrier Precautions (EBP) and a care plan specifying the need for meticulous handwashing and proper use of personal protective equipment (PPE), staff were not informed or reminded of the required precautions. There was no EBP signage or PPE cart placed at or inside the resident's room, and staff were unaware of the need for EBP for this resident. Direct observations revealed that a Licensed Vocational Nurse (LVN) administered medication to the resident without wearing gloves or a gown, and a Certified Nurse Assistant (CNA) provided incontinence care without an isolation gown. Both staff members stated they were not aware that the resident required EBP, and noted the absence of signage and PPE carts that would typically indicate such precautions. Review of facility policies confirmed that EBP should be communicated to staff and PPE made available near or outside the resident's room for high-contact care activities. Interviews with staff, including the Assistant Director of Nursing (ADON), confirmed that the required EBP was not in place for the resident. The facility's own policies and procedures, as well as the resident's care plan and physician's orders, were not followed, resulting in a failure to implement necessary infection control measures for a resident with a multidrug-resistant organism. This lapse was identified through observation, interview, and record review.