Failure to Implement Enhanced Barrier Precautions and Respond to CRE Case
Penalty
Summary
The facility failed to implement its infection control policy and procedures for enhanced barrier precautions (EBP) for a resident who tested positive for Carbapenem Resistant Enterobacterial (CRE). Despite a nurse practitioner (NP) order for EBP following preliminary lab results indicating a wound infection, the resident was not placed on EBP, and no precaution signage or personal protective equipment (PPE) was present at the resident's room. Multiple staff interviews revealed that nursing staff were not made aware of the resident's precaution status, and the only notification system in place was the presence of signage, which was absent. The wound nurse and unit manager both stated that residents requiring wound care should be on EBP, but neither was aware that the resident was not on precautions, and the wound nurse had not noticed the lack of signage or PPE. The Director of Nursing (DON) acknowledged receiving the NP's verbal order for EBP but did not recall why the resident was not placed on precautions or why signage was not posted. The DON had been on vacation and did not designate anyone to cover her responsibilities, resulting in missed communications from the local and state health departments regarding the resident's positive CRE results and recommendations for further action. The DON admitted to not reviewing the toolkit or returning calls and emails from health authorities, and was unaware of the need to test other residents for CRE until after her return. Both the local and state health department representatives reported multiple attempts to contact the facility to discuss the positive CRE result, the need for EBP, and the importance of testing other residents. These communications went unanswered, and the facility did not act on the recommendations until after the deficiency was identified. The administrator and NP both stated that EBP should have been implemented for the resident, and that staff should have been informed of the precaution status, but neither was aware of the lapse until after the fact.