Failure to Follow Enhanced Barrier Precautions During Device Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not ensuring that staff and hospice personnel followed Enhanced Barrier Precautions (EBP) during care of residents with indwelling medical devices. Observations revealed that licensed vocational nurses (LVNs) and a hospice registered nurse (RN) did not wear required personal protective equipment (PPE), such as gowns, when providing care involving a PEG tube and a urinary catheter, despite clear signage and care plans indicating the need for EBP. One resident, a male with severe cognitive impairment, cerebral infarction, dysphagia, and a PEG tube, had physician orders and a care plan requiring EBP, including the use of gowns and gloves during device care. On two separate occasions, LVNs administered medications and tube feeding through the PEG tube while only wearing gloves, omitting the gown. Both the signage on the resident's door and the care plan specified the need for both gown and gloves during such care. The LVNs acknowledged in interviews that they did not follow the required precautions and recognized the importance of doing so. Another resident, also with severe cognitive impairment and a suprapubic catheter, was observed receiving catheter care from a hospice RN who wore gloves but not a gown, contrary to facility policy and posted instructions. The hospice RN stated that this was not standard practice for hospice in home settings, but the facility's contract and policies required adherence to facility infection control protocols. Interviews with facility leadership confirmed that hospice staff are expected to follow facility policies regarding infection control when providing care within the facility.