Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who required enhanced barrier precautions (EBP) due to the presence of a feeding tube. Observations revealed that a CNA and an LVN provided incontinent care and repositioning to the resident without donning the required personal protective equipment (PPE), such as gowns and gloves. There was no signage on the resident's door indicating the need for EBP, nor was PPE available outside the room. The resident's care plan did not address EBP, and there was no physician order for EBP in the resident's records. Interviews with staff confirmed that both the CNA and LVN were aware that residents with feeding tubes should be on EBP and that proper PPE should be used during care. The LVN stated she was unsure why the necessary signage and PPE were not present and admitted to forgetting to use PPE. The DON, who also served as the infection prevention nurse, acknowledged responsibility for ensuring EBP measures were in place and attributed the lapse to the resident's recent room change, during which EBP signage and supplies were not transferred. The facility's policy required EBP for residents with indwelling medical devices, such as feeding tubes, but this protocol was not followed in this instance.