Failure to Implement Enhanced Barrier Precautions During IV Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required by its own infection prevention and control policy for a resident with an indwelling intravenous (IV) line. According to the facility's policy, EBP—including the use of gown and gloves during high-contact resident care activities—must be used for residents at increased risk for acquiring multidrug-resistant organisms (MDROs), such as those with indwelling medical devices. The policy specifically lists activities like IV care as requiring EBP. During an observation, a licensed nurse entered the room of a resident who had an IV line and was receiving intravenous antibiotics. The nurse donned only gloves, omitting the additional personal protective equipment (PPE) required for EBP, and proceeded to set up and administer the IV medication. The nurse did not perform hand hygiene or change gloves during the process. The resident involved had a history of intracranial injury, respiratory failure, and pneumonia, and was actively receiving IV antibiotics at the time of the observation.