Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for a resident who required enhanced barrier precautions (EBP) due to the presence of a PEG tube. Facility policy required that residents needing EBP be identified in their care plans, have discrete signage at their room entrance, and that staff wear gloves and gowns during high-contact care activities, including medication administration via PEG tube. However, the resident's care plan did not include EBP, and there was no EBP signage on the resident's door. During medication administration, the LPN did not don a gown or follow EBP protocols while accessing the PEG tube. Interviews with staff revealed a lack of understanding and awareness regarding EBP requirements. Several staff members were unable to accurately describe when EBP should be used or identify any residents currently under EBP. The Director of Nursing and Administrator also demonstrated limited knowledge of EBP, with the DON stating she did not recall EBP in her training and the Administrator acknowledging the recent creation of a policy. Observations confirmed the absence of EBP signage and the failure to use required personal protective equipment during resident care.