Failure to Implement Enhanced Barrier Precautions and Provide PPE
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to the care plans for two residents who were at high risk for infection transmission due to their medical conditions and devices. For one resident with end-stage renal disease, a gastrostomy, and a hemodialysis port, the care plan required the use of gowns and gloves during high-contact care activities and the posting of EBP signage to alert staff and visitors. However, during observation, there was no EBP signage posted inside or outside the resident's room, and no personal protective equipment (PPE) was available in the room or nearby hallway. The nurse interviewed was unaware of the proper location for PPE and admitted to retrieving PPE from other residents' rooms, which was not in accordance with protocol. The Infection Control Nurse confirmed that signage and PPE should have been present and accessible as per the care plan. Another resident with a history of traumatic brain injury, chronic stage IV pressure ulcer, thoracic spine wound infection, and an indwelling urinary catheter also required EBP per the care plan and physician orders. Observations revealed that there was no EBP signage posted for this resident, and the available PPE in the room was insufficient, consisting of only a couple of gowns. The nurse caring for this resident was unable to locate the required signage and acknowledged that it should have been present. The resident's medical records confirmed recent hospitalization for wound infection and ongoing orders for EBP during high-contact care activities. Facility policy required the use of isolation signs to alert staff, family, and visitors of transmission-based precautions, and specified the use of gowns and gloves for high-contact care activities for residents with certain risk factors. Despite these policies and individualized care plans, the facility did not ensure that EBP signage was posted and that adequate PPE was available and accessible for staff, resulting in a failure to follow established infection prevention and control protocols for the residents reviewed.