Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC line) and an indwelling urinary catheter. According to the facility's policy and CDC guidelines, EBP, including the use of isolation gowns and gloves during high-contact care, should be implemented for residents with indwelling medical devices to prevent the transmission of multidrug-resistant organisms (MDROs). However, during observations, there was no signage posted in the resident's room to alert staff or visitors of EBP requirements, and no personal protective equipment (PPE) such as gloves or gowns was available inside or outside the room. The resident involved had a history of kidney failure, GERD, and high blood pressure, and was admitted with both a PICC line and an indwelling catheter. The clinical record did not include a physician's order for EBP. The Director of Nursing confirmed during an interview that the required signage and PPE were not present, acknowledging that these measures should have been in place for residents with indwelling devices. These findings were based on policy review, clinical record review, direct observation, and staff interview.