Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
A deficiency was identified when a resident with end-stage renal disease and dependence on renal dialysis, who had a permcath (an indwelling medical device) in place, was not placed on enhanced barrier precautions (EBP) as required by facility policy. The physician's orders directed staff to observe the permcath site every shift and monitor for signs and symptoms of infection, but did not include a directive for the use of EBP. The care plan addressed the risk for complications related to dialysis and included monitoring for bleeding at the port site, but did not mention EBP. The facility's EBP list did not identify the resident as requiring EBP, and there was no signage on the resident's door indicating EBP status. During interviews, staff members, including an LPN and the Infection Preventionist, confirmed that the resident had not been placed on EBP and that personal protective equipment (PPE) was not used during care. The DNS acknowledged that the resident should have been on EBP due to the presence of the permcath and that appropriate orders and signage were missing. Facility policy states that EBP should be used for residents with indwelling medical devices, regardless of MDRO colonization, but this was not implemented for the resident in question.