Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a midline catheter who required infection control measures to reduce the spread of multidrug-resistant organisms (MDROs). The resident, who had severe cognitive impairment and was always incontinent of bladder and bowel, was admitted with multiple diagnoses and was receiving intravenous Vancomycin through a midline in her right upper arm. The care plan specified that staff should use personal protective equipment (PPE) such as gown and gloves during high-contact care activities, including toileting and changing briefs, and that appropriate signage should be posted to alert staff to the EBP requirements. During observations and interviews, it was found that there was no EBP signage outside the resident's room or above her bed, and a CNA caring for the resident was unaware she was on EBP, mistakenly believing it was her roommate. The CNA did not use PPE when toileting the resident, and later acknowledged this was an error. The Infection Preventionist and DON confirmed that PPE should have been used for high-contact care activities for this resident. Review of facility policy also indicated that EBP, including gown and gloves, should be used for residents with indwelling medical devices during high-contact care.