Failure to Implement Enhanced Barrier Precautions for Resident with Central Line
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a central line who was receiving intravenous Vancomycin for an infection related to an internal joint prosthesis. According to the facility's own EBP policy, residents with indwelling medical devices such as central lines are required to be placed on EBP, which includes the use of gowns and gloves by staff during high-contact care activities. However, during direct observation, a registered nurse provided care to the resident by flushing the central line and administering medication while only wearing gloves and not donning a gown. The nurse also confirmed that the resident was not on EBP at the time of care. Further review revealed that the resident's care plan did not include any documentation or plan for EBP, despite ongoing treatment for infection via a central line. Interviews with the Director of Nursing confirmed that all residents with central lines should be on EBP and that this particular resident was never placed on such precautions. The lack of signage and absence of an EBP care plan contributed to the failure to implement the required infection prevention measures for the resident.