Failure to Implement Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own policy and current infection control standards during percutaneous endoscopic gastrostomy (PEG) tube care for one resident. During an observed care event, a registered nurse performed PEG tube care without donning a gown, despite facility policy and posted signage requiring both gown and gloves for high-contact care activities involving indwelling medical devices such as feeding tubes. Interviews with the nurse, the infection preventionist, and the director of nursing confirmed that a gown should have been worn during this procedure to protect the resident from potential contamination from the staff member's uniform. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, and was assessed as having moderate cognitive impairment. Physician orders required daily cleaning and dressing of the PEG tube site. Facility records and staff interviews indicated that the resident was at high risk for infection due to the presence of the PEG tube, and that failure to use a gown during care could result in the transfer of organisms from staff to the resident.