Failure to Implement Enhanced Barrier Precautions for Residents with PICC Lines
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents who had peripherally inserted central catheter (PICC) lines and were receiving intravenous antibiotic infusions. Both residents were admitted with prosthesis infections and had PICC lines inserted prior to admission. Observations revealed that neither resident had EBP signage or personal protective equipment (PPE) available in their rooms, and nursing staff did not use PPE when administering medications. Medical orders for both residents did not include instructions for EBP, and there was no evidence that EBP was initiated upon admission as required by facility policy. Interviews with facility staff, including a nurse practitioner, RN, and the director of nursing, confirmed that EBP should have been implemented for residents with PICC lines, in accordance with the facility's infection prevention and control policy. The policy specifies that EBP precautions, including clear signage and PPE availability, are required for residents with devices such as PICC lines. Despite this, the necessary precautions were not in place for either resident, as confirmed by staff and direct observation.