Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) during the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had a history of cancer, anemia, quadriplegia, non-Alzheimer's dementia, and chronic atrial fibrillation, was identified as requiring EBP due to the presence of an indwelling medical device. Facility policy and CDC guidance required staff to wear gloves and a gown for all high-contact activities, including device care such as cleaning and flushing a PEG tube. During an observed care event, a Licensed Practical Nurse (LPN) cleaned the resident's PEG-tube site and performed a water flush without donning a gown, despite signage and care plan instructions indicating the need for EBP. Staff interviews confirmed awareness of the EBP requirements, and the LPN's personnel file showed documented competency in EBP procedures. The Assistant Director of Nursing (ADON) acknowledged that a gown should have been worn and that gowns were available in the resident's closet. The facility's policy, updated prior to the event, clearly outlined the need for gowns and gloves during high-contact care for residents with indwelling devices, and the EBP status was communicated through door signage and the care plan. Despite these measures, the required PPE was not used during the observed care activity.