Failure to Implement Enhanced Barrier Precautions for Residents with Medical Devices and Wounds
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing and following enhanced barrier precautions (EBP) for two residents who required such measures. For one resident with a peripherally inserted gastrostomy tube (PEG) and an active order for enteral feeding, an LPN administered medications through the PEG tube without donning a gown, despite an EBP sign on the door instructing staff to wear gown and gloves for all high-contact care activities. The LPN stated she was trained on EBP but was unaware that gown use was mandatory in this situation. For another resident with multiple wounds requiring ongoing wound care, there was no EBP sign on the door, and the wound care nurse reported that the resident was not on any transmission-based precautions. The infection preventionist and DON confirmed that residents with wounds should be on EBP, with appropriate signage and PPE available in the resident's room. However, the facility practice was to only use PPE during wound care and not to post EBP signage or maintain PPE in the room, contrary to established protocols.