Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for three residents who were identified as requiring them, as observed during a survey. For one resident with an intravenous midline for antibiotic administration, there was no evidence of EBP, such as signage or personal protective equipment (PPE), at the bedside despite a physician's order for EBP related to intravenous access. The DON confirmed that EBP was not in place at the time of observation and stated that PPE was kept in resident bathrooms and signs were posted on name cards by the doorway, but these measures were not observed in practice. Another resident with a Foley catheter, ordered to have EBP due to the indwelling device, was also observed without appropriate signage or PPE in place. The DON confirmed the absence of EBP for this resident as well. A third resident with wounds, including a deep tissue injury and moisture-associated skin damage, had a care plan and physician order for EBP due to increased risk of multidrug-resistant organism (MDRO) acquisition, but EBP was not initiated until after the survey process began. Facility policy and CDC guidance require EBP for residents with wounds or indwelling devices, but these were not consistently implemented as required.