Failure to Implement Enhanced Barrier Precautions for High-Risk Resident
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with significant risk factors for multidrug-resistant organism (MDRO) transmission. Specifically, a resident who was admitted with an indwelling urinary catheter, a Stage 4 pressure ulcer, and a wound infection did not have EBP implemented upon admission, despite facility policy and federal guidance requiring gown and glove use during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of known MDRO status. Documentation showed that EBP was not initiated until after the resident was removed from contact precautions for an MDRO, and there was no evidence of an EBP order or care plan addressing these precautions at the time of admission. Interviews with the Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP was not documented or ordered when the resident was admitted, and the care plan was only updated after contact precautions were discontinued. The lack of timely implementation and documentation of EBP for this high-risk resident constituted a failure to adhere to both facility policy and current infection control standards, as required by regulatory guidelines.