Failure to Implement Enhanced Barrier Precautions for Resident with Wound and Indwelling Device
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy and standard infection control practices for a resident with a surgical wound and an indwelling medical device. According to the facility's EBP policy, residents with wounds or indwelling medical devices require a physician order for EBP, and personal protective equipment (PPE) such as gowns and gloves should be immediately available near or outside the resident's room. Additionally, a trash can should be positioned inside the room near the exit for discarding PPE prior to leaving. Record review showed that the resident was readmitted with osteomyelitis, enterococcus infection, a surgical wound, and a peripherally inserted central catheter (PICC) for intravenous antibiotics, but there was no physician order for EBP as required by policy. Surveyor observations revealed that gowns and gloves were not immediately available near or outside the resident's room, and a trash can for discarding PPE was not positioned as required. The resident reported that staff did not wear gowns when providing personal care. Interviews with nursing staff and the Director of Nursing confirmed that EBP should have been in place for the resident due to the presence of wounds and a PICC line, but these precautions were not implemented.