Failure to Post Enhanced Barrier Precaution Signage and Ensure PPE Use
Penalty
Summary
The facility failed to follow its own policy regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or open wounds. According to the facility's policy, EBP signage indicating the required personal protective equipment (PPE) must be posted outside the rooms of residents with wounds, urinary catheters, G-tubes, or those receiving dialysis, regardless of MDRO colonization. Surveyors observed that for 13 residents with such conditions, there was no EBP signage posted on their doors or walls to indicate the necessary PPE for direct care activities. Multiple observations confirmed the absence of EBP signage for residents with chronic kidney disease, end stage renal disease, neuromuscular dysfunction of the bladder, gastroesophageal reflux disease with G-tube, pressure ulcers, and other relevant diagnoses. In several instances, staff members, including LPNs and CNAs, provided direct care to these residents without donning the appropriate PPE as required by EBP protocols. For example, an LPN was observed handling a central venous catheter dressing without gloves, and a CNA changed a resident's brief while only wearing gloves and not a gown. Interviews with the Director of Nursing and the Infection Preventionist confirmed that residents with dialysis, wound care, urinary catheters, and G-tubes were supposed to be on EBP, and staff were expected to wear gowns and gloves during direct resident contact. Despite this, the required signage was not present, and staff did not consistently use the appropriate PPE during high-contact care activities for these residents.