Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a resident with multiple wounds and a peripherally inserted central catheter (PICC) line did not have enhanced barrier precautions (EBP) implemented as required. Despite physician orders for wound care and PICC line monitoring, there was no EBP signage or supplies outside the resident's room. Interviews with staff, including a CNA, LPN, and the Director of Nursing, revealed a lack of awareness and implementation of EBP for residents with wounds and indwelling catheters, including PICC lines. Staff reported not using gowns during care and were unsure about the need for EBP in such cases. Additionally, during a meal service, a plate guard that had fallen to the floor was picked up and placed back on the resident's plate by a CNA, without being cleaned or replaced. The CNA was unaware that the plate guard had been on the floor, and the Administrator later confirmed that the expectation was for dropped items to be replaced with clean ones and not reused. These actions demonstrated a failure to maintain proper infection prevention and control practices for the resident.