Failure to Post Enhanced Barrier Precautions Signage for Resident with Permcath
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program by not posting Enhanced Barrier Precautions (EBP) signage for a resident who had a permcath for dialysis. The resident, a female recently admitted with diagnoses including dependence on renal dialysis, diabetes mellitus, acute kidney failure, and hypertensive heart disease, required EBP due to the presence of an indwelling medical device. The care plan and physician orders indicated the need for EBP, including the use of gowns and gloves for high-contact care activities, and the facility's policy required signage to alert staff to these precautions. Despite these requirements, observations revealed that no EBP sign was posted on the resident's door. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that the resident should have been under EBP from the date of re-admission and that the absence of signage was an oversight. Staff acknowledged that the lack of signage could result in staff not taking proper infection control precautions when providing care to the resident. The facility's own policy, reviewed as part of the investigation, specified that EBP signage should be posted for residents with indwelling medical devices such as permcaths. The failure to post the required signage was attributed to staff oversight, with multiple staff members confirming their responsibility to ensure signage was in place and acknowledging that it had not been done.