Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound and Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them due to an open wound and the presence of a catheter. The resident, who was moderately cognitively impaired and admitted for rehabilitation after hospitalization, had a care plan indicating the need for EBP. However, during multiple observations, there was no EBP signage on the resident's door, and staff were seen entering the room and providing direct care without donning personal protective equipment (PPE) as required by the facility's EBP policy. Interviews with staff revealed a lack of clarity regarding responsibility for placing EBP signage and understanding of when EBP should be implemented. The admit nurse did not place the required signage during the admission process, and the infection control nurse did not identify the omission during routine checks. Additionally, a nursing assistant was unsure about the specific indications for EBP, and the administrator confirmed that the signage had not been placed as required.