Failure to Follow Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow the facility's infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors for infection. The resident had been admitted with diagnoses including staphylococcal arthritis, methicillin susceptible staphylococcus aureus infection, cellulitis, and a cutaneous abscess, and had a central line in place. Physician orders specified the use of EBP, requiring personal protective equipment (PPE) such as gown and gloves for high-contact care activities due to the presence of wounds and a central line. During an observation, the registered nurse entered the resident's room to disconnect an IV line and flush the central line, but only donned gloves and did not wear a gown as required by EBP protocols. The Assistant Director of Nursing confirmed in an interview that EBP should be applied for residents with central lines and wounds, and that staff are informed of these requirements through physician orders. Review of the facility's infection control policy further confirmed that both gown and gloves are required for high-contact care activities involving central lines or wounds.