Failure to Follow Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines for two residents who required such precautions due to the presence of indwelling medical devices. For one resident with hemiplegia, muscle weakness, aphasia, diabetes, dysphagia, and chronic kidney disease, staff were observed performing urinary catheter care without donning gowns as required by EBP protocols. Both CNAs involved only wore gloves and admitted to forgetting to wear gowns, despite EBP signage and supplies being available in the resident's room. Additionally, the catheter care procedure did not follow the facility's policy, as the CNA wiped the catheter tubing before the perineal area and used the same gloves throughout the process, including for handling supplies and applying ointment. For another resident with muscle weakness, dysphagia, expressive language disorder, and adult failure to thrive, who was receiving tube feeding, there was no EBP signage posted in the room or on the door. Multiple staff members, including a registered nurse and two CNAs, were unaware of which residents required EBP or the criteria for implementing EBP. The registered nurse, who was responsible for residents with devices such as a dialysis access port, did not recognize the need for EBP and could not identify the location of necessary supplies or signage. Observations confirmed the absence of EBP signage for residents with qualifying devices, and staff interviews revealed a lack of knowledge regarding EBP requirements. The infection preventionist confirmed that EBP should be implemented for all residents with devices such as PEG tubes, dialysis ports, tracheostomies, colostomies, or wounds, and that staff must wear gowns and gloves during care. The infection preventionist also acknowledged the absence of required EBP signage for the resident receiving tube feeding and confirmed that staff education on EBP was lacking at the time of the survey.