Failure to Follow Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
A deficiency occurred when a registered nurse failed to follow proper infection control practices during medication administration for a resident with multiple complex medical conditions, including a central line and total parenteral nutrition (TPN). The nurse did not perform hand hygiene between glove changes while preparing TPN medications and did not wear a gown when cleaning and accessing the resident's central line, despite facility policies and physician orders requiring enhanced barrier precautions (EBP) for residents with indwelling medical devices. The resident involved was moderately cognitively impaired, dependent on staff for activities of daily living, and had a care plan and physician orders specifying the use of gown and gloves during high-contact care activities due to the presence of a central line. The Director of Nursing confirmed that staff are required to wear gloves and a gown when accessing a central line under EBP and to perform hand hygiene between glove changes, which was not followed in this instance.