Failure to Follow Enhanced Barrier Precautions During PEG Tube Site Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident with a gastrostomy tube. The resident had diagnoses including cerebral palsy, dysphagia, and gastrostomy status, and received continuous enteral feeding via a PEG tube, with orders for EBP in place. Care plans documented that the resident required EBP due to the gastrostomy tube and that staff were to follow EBP during care and minimize infection risk related to the tube site. During an observation, an EBP magnet was posted outside the resident’s room, and PPE (a yellow isolation gown and gloves) was available inside the room. The Unit Manager prepared to perform PEG site care, performed hand hygiene, and wore gloves, but did not don an isolation gown. She cleansed the PEG insertion site using soapy washcloths, working from the insertion site outward and using different edges of the washcloth, then rinsed and dried the area. A scant amount of tan drainage was observed on the washcloth during cleansing. Throughout this high-contact device care activity, the Unit Manager did not wear a gown despite the facility’s EBP policy identifying feeding tube care as a high-contact resident care activity requiring gown and glove use. In interviews, the Unit Manager stated she believed gowns were only needed when dealing with the tube feeding itself or if the PEG site was red, infected, inflamed, had drainage, or if splattering might occur, and that gloves alone were sufficient for personal care. The DON initially indicated that EBP, including gown use, was required for personal care such as PEG site care and that the PEG site was the reason for the resident’s EBP status, but later acknowledged conflicting information received from the Infection Preventionist and then confirmed that a gown should have been worn. The Infection Preventionist reported conducting EBP rounding and education but stated she did not believe a gown was needed for this PEG site care because the GI tract was not sterile, there was no chance of splash, no prolonged contact, and the PEG site was old with no drainage observed, and indicated she would have done the same as the Unit Manager. The facility’s written EBP policy, however, specified that residents with feeding tubes require EBP and that PPE (gown and gloves) is necessary when performing high-contact care activities, including device care such as feeding tubes, for the duration of the resident’s stay or until the device is discontinued.
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