Failure to Follow Enhanced Barrier Precautions During Peritoneal Dialysis Catheter Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program by not following Enhanced Barrier Precautions (EBP) during a dressing change for a resident with a peritoneal dialysis catheter. The resident, who had chronic kidney disease stage five and type two diabetes, required peritoneal dialysis and had a care plan directing staff to use EBP, including wearing gowns and gloves during high-contact care activities such as wound care. During an observed dressing change of the resident's abdominal peritoneal dialysis catheter, the licensed nurse wore gloves but did not wear a gown as required by the facility's policy and the resident's care plan. The nurse later acknowledged that a gown should have been worn during the procedure. The administrative nurse confirmed that the expectation was for staff to use both gown and gloves for residents under EBP. The facility's policy on multidrug-resistant organisms and EBP specifically requires targeted gown and glove use during high-contact resident care activities to reduce transmission risks. The failure to adhere to these precautions was directly observed during the dressing change procedure.