Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for seven residents who had conditions or medical devices that, according to facility policy and professional standards, required such precautions. These residents included individuals with nephrostomy tubes, PICC lines, Foley catheters, G-tubes, tracheostomies, and chronic wounds. Despite physician orders for care related to these devices, the care plans did not reflect the need for EBP protocols or interventions. There was also no evidence of interdisciplinary communication to ensure EBP measures were in place, and no signage was posted outside the rooms of affected residents to alert staff to the need for EBP. Personal protective equipment was not readily accessible for staff use in these cases, and documentation did not indicate any resident refusals regarding infection control care plans. Observations and staff interviews revealed inconsistent understanding and implementation of EBP protocols. Some staff reported following EBP procedures only when signage was present, while others relied on verbal instructions from nursing staff. The DON/Infection Preventionist stated that EBP was only applied to residents with active multidrug-resistant organisms (MDROs), despite the facility's policy requiring EBP for all residents with certain indwelling devices or wounds, regardless of MDRO status. The DON acknowledged a lack of signage and EBP implementation for residents who met the criteria, confirming that the current practice did not align with federal guidelines or facility policy.