Failure to Post EBP Signage and Enforce PPE Use for Residents on Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not posting required Enhanced Barrier Precautions (EBP) signage and not ensuring proper use of personal protective equipment (PPE) for a resident on contact precautions. One resident with chronic conditions including COPD, end stage renal disease (ESRD), dependence on hemodialysis, and a central venous dialysis access in the right chest had physician orders and a care plan indicating the need for EBP due to the invasive dialysis access site. During observation, this resident was found resting in bed with a visible dialysis catheter dressing, but there was no EBP signage posted at the room entrance, contrary to the resident’s care plan and the facility’s EBP policy, which require door signage and PPE guidance for staff and visitors. A second resident, admitted with multiple diagnoses including ESRD, diabetes, liver disease, transplant-related conditions, MRSA infection, and C. difficile enterocolitis, was on contact precautions for ESBL in the urine, as later confirmed by the infection preventionist (IP) nurse. At the time of surveyor observation, there was contact precautions signage on the door instructing everyone to don gloves and gown before room entry. However, a visitor was observed inside the room sitting and talking with the resident without wearing any PPE, and a CNA was later observed entering the room and assisting the resident with lunch while wearing gloves but no gown, despite the posted requirement for both gloves and gown upon entry. Interviews with the IP nurse and the DON confirmed that residents on EBP should have door signage and accessible PPE, and that residents on contact precautions require a physician order, care plan, and use of gloves and gowns by staff and visitors when entering the room. Review of the second resident’s electronic health record with the IP nurse initially showed no physician order or care plan for contact precautions at the time of the observations. The facility’s written policies for EBP and infection control/isolation guidelines specify that appropriate PPE must be used, proper signage must be posted on resident room doors, and that contact precautions require gloves and gowns upon room entry and must be ordered by a physician and care planned, all of which were not fully implemented for the residents observed.
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