Failure to Implement Enhanced Barrier Precautions Signage and Staff Awareness
Penalty
Summary
The facility failed to implement its policy regarding Enhanced Barrier Precautions (EBP) for residents requiring such precautions. Specifically, there was a lack of clear signage or instructions on resident doors indicating the required personal protective equipment (PPE) and care activities necessitating PPE use. Observations revealed that rooms of nine residents on EBP only had a magnetic square labeled 'EP' without further information, and some rooms lacked any signage or had incorrect precaution signs. Staff interviews indicated inconsistent understanding of what PPE to use for EBP, with some staff stating they would don full PPE but lacking specific guidance at the point of care. The Director of Nursing confirmed that there was no signage at the door, and staff would need to look inside the room or in the resident's chart to determine PPE requirements. Medical record reviews for several residents showed that while care plans indicated the need for EBP due to conditions such as complex wounds, laryngostomy tubes, urinary catheters, and PICC lines, there were no corresponding physician orders for EBP. The facility's policy required staff training and posting of signs outside resident rooms to alert staff to EBP requirements, but this was not consistently followed. The deficiency was identified through medical record review, staff interviews, and direct observation during the survey.