Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring staff adhered to Enhanced Barrier Precautions (EBP) for two residents who were at increased risk of infection due to the presence of indwelling medical devices and ongoing antibiotic therapy. For one resident with an indwelling urethral catheter and a diagnosis of infection and inflammatory reaction, staff did not use required personal protective equipment (PPE) such as gloves and gowns while administering and discontinuing intravenous antibiotics and flushing a PICC line, despite clear signage and physician orders for EBP. Similarly, another resident with diagnoses including endocarditis and pneumonia, and who had a G-tube and was receiving intravenous antibiotics, did not receive care in accordance with EBP. The registered nurse failed to use PPE while administering IV medications, flushing the IV, and managing the G-tube, contrary to physician orders and facility policy. Interviews with nursing staff and leadership confirmed that PPE should have been used during these high-contact care activities, and the facility's policy required EBP for residents with indwelling devices or wounds.