Failure to Follow Enhanced Barrier Precautions During IV Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the implementation of Enhanced Barrier Precautions (EBP) for a resident receiving intravenous (IV) therapy. During a medication administration observation, a registered nurse performed hand hygiene and donned gloves but failed to wear a gown as required by the facility's EBP policy when providing central line care. The nurse administered IV medication and handled the resident's IV site without the additional protective equipment mandated for residents under EBP. The resident involved had been admitted with a diagnosis of osteomyelitis of the vertebra and was receiving antibiotic therapy via IV for this condition. The care plan for this resident included interventions specifying the use of Enhanced Barrier Precautions due to the presence of an IV line, which is considered a high-contact area and a potential source of cross-contamination. Facility policy and staff interviews confirmed that both gloves and gowns are required for staff when providing care to residents under EBP, particularly during high-contact activities such as IV administration. Interviews with the risk manager and the nurse involved confirmed that the facility's protocol was not followed during the observed care. The risk manager stated that staff are educated to wear both gloves and gowns for residents under EBP, and signage and PPE caddies are used to support compliance. The nurse acknowledged awareness of the requirement but did not don a gown during the observed procedure, attributing the lapse to nervousness. This failure to adhere to established infection control protocols constituted the cited deficiency.
Plan Of Correction
The Nurse-Staff A was immediately reeducated by the Director of Quality Assurance on 7/15/2025 on enhanced barrier precautions (EBP) and the usage of Personal Protective Equipment (PPE) during medication administration via central line. Resident #2 is receiving IV antibiotic therapy, and enhanced barrier precautions are being observed during IV administration and other tasks requiring EBP. An audit was completed by the Director of Clinical Services on 7/18/25 of all current residents with central lines to ensure that enhanced barrier precautions were adhered to when administering IV medications. Licensed staff were re-educated by the Director of Education or designee starting on 7/21/25 on infection control practices to include enhanced barrier precautions and appropriate PPE while administering medication via central line. Weekly audits/observations will be conducted for 4 weeks, then monthly for 3 months, by the Director of Clinical Services or designee to ensure that licensed staff are adhering to enhanced barrier precautions and appropriate Personal Protective Equipment is worn during medication administration for residents with central lines. Findings of audits will be reported to QAPI to ensure ongoing compliance.