Failure to Post Enhanced Barrier Precaution Signage for Dialysis Resident
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precaution (EBP) signage was in place for a resident requiring infection control measures. Observations on multiple occasions revealed that there was no EBP signage inside or outside the resident's room, despite a physician's order for EBP every shift due to end stage renal disease and dialysis. Supplies such as gowns, shields, masks, and gloves were available in a cabinet near the room, but the required signage to indicate EBP precautions was missing. Interviews with staff confirmed that there were two residents on EBP for dialysis, and that signage was supposed to be posted on or near the door, but it was not present for this resident. Staff interviews indicated confusion and inconsistency regarding the responsibility for posting EBP signage, with some staff stating it was the DON's responsibility and others noting that residents sometimes removed the signs. The DON initially stated that signage was present but later confirmed its absence upon inspection. The resident involved was cognitively intact, received dialysis, and had a diagnosis of end stage renal disease. The lack of proper signage led to uncertainty among staff about which residents were on EBP and inconsistent use of personal protective equipment (PPE) when caring for the resident's dialysis catheter.