Failure to Post EBP Signage and Ensure PPE Use for Resident with Indwelling Device
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring Enhanced Barrier Precaution (EBP) signage was posted for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, as required by facility policy. Observations on two separate occasions revealed that no EBP signage was present on or around the resident's door or bed, despite physician orders and care plan documentation indicating the need for EBP due to the presence of an indwelling medical device. Staff interviews confirmed the absence of signage and acknowledged that it should have been posted to alert staff and visitors. Additionally, staff did not consistently wear the required personal protective equipment (PPE), specifically gowns, during high-contact care activities for the resident on EBP. Observations showed that an LPN performed PEG tube care and two staff members conducted a transfer using a Hoyer lift without wearing gowns, contrary to facility policy and the resident's care plan. Interviews with the involved staff revealed a lack of awareness that the resident was on EBP and an acknowledgment that gowns should have been worn during these activities. The Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP signage and appropriate PPE use were required but not followed in these instances.