Failure to Implement Enhanced Barrier Precautions for Resident with ESBL Infection
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident who was admitted with a peripherally inserted central catheter (PICC) line and an active infection, specifically an Extended Spectrum Beta Lactamase (ESBL) urinary tract infection. Upon observation, the resident reported that nursing staff did not wear gowns or other personal protective equipment (PPE) when providing care, and there was no signage or PPE available near the resident's room to indicate the need for such precautions. The resident's medical record and care plan did not include any orders or instructions for enhanced barrier or transmission-based precautions at the time of review. Further review of the resident's medical history showed they required assistance with most activities of daily living and had intact cognition. The infection control preventionist confirmed that the resident should have been on contact precautions due to the ESBL infection and the presence of a PICC line, but acknowledged that the resident was missed during the initial review for precaution requirements upon admission. The deficiency was identified through observation, interview, and record review, which revealed a lack of appropriate infection control measures for the resident in question.