Failure to Implement Enhanced Barrier Precautions for Resident with CRE
Penalty
Summary
The facility failed to follow its infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) for a resident colonized with Carbapenem-resistant Enterobacteriaceae (CRE), a multidrug-resistant organism. Specifically, there was no sign indicating EBP and no cart with the required personal protective equipment (PPE) such as gowns, gloves, eye protection, or facemasks outside or near the resident's room. This was observed during a time when the resident was in her room with a visitor, and a maintenance worker was present, indicating that multiple individuals could have entered the room without proper precautions. Record review showed that the resident had a history of chronic obstructive pulmonary disease and heart failure, and was identified as colonized with CRE following an acute care stay. Physician orders and the care plan both specified the need for EBP to prevent transmission, and facility policy required PPE to be available near or outside the room for residents with MDROs. The Infection Preventionist confirmed the absence of both the EBP sign and PPE cart, acknowledging that this could result in staff not knowing the proper PPE to use during direct care.