Failure to Implement Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the improper implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling Foley catheter. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, such as urinary catheters, to prevent the spread of multidrug-resistant organisms (MDROs). However, observations revealed that a nurse did not wear the required personal protective equipment (PPE) when exposing and administering a Lidocaine patch to the resident's lower back and when handling the resident's Foley catheter drainage bag. The resident involved had a history of lumbar vertebra fracture, spinal stenosis, and obstructive and reflux uropathy, and was dependent on staff for multiple activities of daily living. The resident utilized a wheelchair and had bilateral upper and lower extremity impairments. Physician orders and facility policy indicated that EBP should be implemented for this resident due to the presence of a Foley catheter, with specific instructions for PPE use during high-contact care activities. Interviews with nursing staff, the infection preventionist, and the director of nursing revealed inconsistent understanding and application of EBP requirements. Staff provided varying explanations regarding when gowns should be worn, with some indicating that gowns were only necessary when there was a risk of fluid exposure or direct skin contact, and others acknowledging that gowns should be worn for any contact with the Foley catheter or during medication administration involving direct resident contact. Facility policies reviewed by surveyors confirmed the expectation for PPE use in these scenarios, but the observed practices did not align with these requirements.
Plan Of Correction
F-tag 880 1. Corrective Action for residents found to have been affected: • Resident 21 is no longer in the facility as of 05/22/2025. • The IP Nurse will conduct direct observation of • LVN 1 was provided one-on-one in-service by the IP Nurse on 5/18/2025 regarding donning and doffing of PPE with residents on Enhanced Barrier Precaution (EBP). II. Facility's Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 5/28/2025, the IP Nurse conducted a direct observation on random facility staff in regard to proper donning and doffing of PPE with residents on EBP. 5/5 facility staff were observed and all are compliant. • No other residents were affected by the deficient practice. III. Measures and systemic changes put in place to ensure deficient practices do not recur: • The IP Nurse provided in-service to facility staff on 05/18/2025, regarding the policy and procedure for Enhanced Barrier Precaution (EBP). The goal is to prevent and control the risks of spreading infectious microorganisms to residents. • Facility staff will be observed for 1 month, then monthly, with 5 staff observations to ensure proper donning and doffing of PPE when in contact with residents on EBP. • Audit findings will be reported to the DON for follow-up. IV. Facility's plan to monitor corrective actions to achieve & sustain compliance: • The IP Nurse will report findings of donning and doffing observations during the monthly QAA meeting for 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025