Failure to Follow Enhanced Barrier Precautions for Resident With PEG Tube
Penalty
Summary
Surveyors identified a failure to follow the facility’s own infection prevention and control policy regarding Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The facility’s policy, dated 04/15/2025, required implementation of EBP, including use of gowns for high-contact resident care activities such as device use with feeding tubes, for residents with indwelling medical devices even if they were not known to be infected or colonized with multidrug-resistant organisms. The policy also stated that all staff were to receive training on EBP upon hire and at least annually and were expected to comply with all designated precautions. The resident involved was admitted on 09/04/2025 and had diagnoses including anoxic brain damage, dysphagia following cerebral infarction, gastrostomy, moderate protein-calorie malnutrition, personal history of sudden cardiac arrest, and aphasia following other cerebrovascular disease. The quarterly MDS showed the resident had severe cognitive impairment and was dependent for multiple ADLs, including hygiene and bathing. The resident had a PEG feeding tube and a care plan addressing PEG tube feedings. An EBP sign was posted on the resident’s room door. During observation of medication administration, an LPN administered medications and tube feeding through the PEG tube without donning a gown. In a subsequent interview, the LPN acknowledged the resident was on EBP due to the PEG tube and confirmed she did not wear a gown, and the DON and ADON stated that a gown should be worn for direct contact with residents on EBP and confirmed a gown should have been worn during this care but was not.
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