Failure to Implement Enhanced Barrier Precautions for Resident with Infection Risks
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with significant infection risks, including a gastrostomy and an indwelling urinary catheter. The resident's care plan indicated the need for Enhanced Barrier Precautions (EBP), but there was no physician's order for EBP in the medical record, and EBP signage was not present at the entrance or inside the resident's room. During observation, a nurse provided direct care to the resident using gloves but did not don a gown as required by EBP protocols. The nurse left the facility before a follow-up interview could be conducted. Interviews with staff revealed a lack of awareness and understanding regarding the implementation of EBP for the resident. The primary nurse was unsure if EBP was required and could not locate the necessary signage or physician's order. The Assistant Director of Nursing, responsible for the infection prevention program, was unaware that the EBP order was missing and could not explain the absence of signage. The facility's policy required targeted gown and glove use and the posting of precaution signs, but these measures were not followed for the resident in question.