Failure to Implement Enhanced Barrier Precautions and Device Disinfection
Penalty
Summary
The facility failed to implement its own policies regarding Enhanced Barrier Precautions (EBP) and the cleaning and disinfection of a point-of-care device. During observation, a glucometer was found on top of a medication cart with a dried pink/red smear on its back, and a Licensed Practical Nurse confirmed that the glucometer should be cleaned after each use with EPA-approved disinfectant wipes, as per facility policy. Review of the policy confirmed the requirement to clean and disinfect the blood glucose meter after each use, but the observed condition of the glucometer indicated this was not done. Additionally, the facility did not follow its EBP policy for two residents who required these precautions due to chronic wounds, a PICC line, and an indwelling Foley catheter. In one case, a Registered Nurse provided perineal care to a resident with wounds and a PICC line while wearing only gloves and not a gown, despite an active physician's order and care plan for EBP. In another case, a Licensed Nursing Assistant provided personal hygiene to a resident with an indwelling Foley catheter while wearing gloves but not a gown, and initially stated the resident was not on EBP, which was later contradicted by another staff member and the resident's medical record. The Infection Preventionist confirmed that the facility policy required both gown and gloves for high-contact care activities for residents on EBP.