Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement and follow its own infection prevention and control program, specifically regarding enhanced barrier precautions (EBP) for residents with indwelling medical devices. For one resident with a Foley catheter, multiple observations revealed the absence of EBP signage and the lack of required infection control supplies such as gowns and gloves at the room entrance. Additionally, the resident's catheter bag was observed on the floor during several visits. Staff interviews confirmed that the necessary signage and supplies were not present as required by facility policy and physician orders. Another resident with a nephrostomy tube also did not have EBP signage at the doorway, despite physician orders and care plans indicating the need for enhanced barrier precautions. The infection preventionist confirmed the lack of appropriate signage, and the assistant director of nursing described a process for communicating EBP status that was not reflected in practice for these residents. These failures created the potential for cross-contamination and did not comply with the facility's infection control policies.