Failure to Implement Enhanced Barrier Precautions for Resident with Infected Wound and PICC Line
Penalty
Summary
A deficiency occurred when the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who was admitted with an infected right above-the-knee amputation stump and a peripherally inserted central catheter (PICC) line for long-term intravenous antibiotics. The resident required maximal assistance with several activities of daily living and had an open, infected wound with serous drainage. Despite these risk factors, which were documented in the resident's admission records and assessments, EBP was not initiated upon admission as required by facility policy. The resident's name tag outside the room did not display the orange sticker indicating EBP status, and staff did not wear gowns or gloves when providing direct care. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that the resident met the criteria for EBP due to the presence of a PICC line and an infected wound. The IPN acknowledged that the resident was not placed on EBP for approximately 19 days because the need for precautions was overlooked. Facility policy required the use of gowns and gloves for residents with indwelling medical devices or open, non-healing wounds, and the absence of proper signage and staff adherence led to the failure in implementing necessary infection control measures.