F0880

D

Failure to Implement Enhanced Barrier Precautions for Resident With PEG Tube

Saginaw, Michigan Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling percutaneous endoscopic gastrostomy (PEG) tube. The resident was admitted for skilled nursing care with multiple diagnoses including cerebral edema, oropharyngeal dysphagia, severe protein-calorie malnutrition, metastatic lung cancer with bone metastases, and had a PEG tube placed prior to or at the time of admission. The resident’s MDS showed a BIMS score of 11/15, indicating moderately impaired cognition. Facility policy and the DON/Infection Control Preventionist’s (ICP) own EBP quick reference guide both identified feeding tubes as indwelling medical devices that require EBP.

On observation of the resident’s room, surveyors noted there was no EBP signage posted on the door, no PPE immediately present at the door, and no PPE receptacle in the room. The resident reported that staff assisted with daily care such as showers and that he could perform his own oral care and grooming, and ambulate to the restroom with a walker, but he stated that staff did not wear gowns when providing care or handling his tube feeding or dressing, questioning why they would need a gown. This contrasted with the facility’s EBP policy, which required gown and glove use during high-contact resident care activities and care and use of indwelling medical devices, including feeding tubes.

Record review showed multiple orders related to the PEG tube, including checking the tube site every shift for signs of infection and complications, monitoring for signs of misplaced tube, changing the irrigation kit every 24 hours, and providing enteral tube site care. However, there were no orders for EBP in the resident’s chart. The resident’s care plan addressed nutritional risk and the need for a feeding tube, including interventions for tube feeding administration, tube placement checks, positioning, lab monitoring, and reporting signs and symptoms of infection, but it did not include any interventions related to EBP. The DON/ICP confirmed during interview that residents with indwelling devices such as feeding tubes are required to be on EBP, that residents on EBP should have signage on the door and PPE available, and that the facility only had EBP in place at that time. During a hall walk-through, the DON/ICP identified five residents on EBP based on posted signage, but did not identify this resident. After reviewing the resident’s chart, care plan, Kardex, and orders, the DON/ICP acknowledged there was no EBP sign, no EBP order, and no EBP care plan for this resident and stated that staff had probably not followed EBP for the resident since admission because of this lack of identification and documentation.

The facility’s written EBP policy specified that residents with indwelling medical devices, including feeding tubes, are required to be placed in EBP, that a physician order is to be obtained, that EBP signage is to be posted outside the resident’s room, and that gowns and gloves are to be available outside the room and used during high-contact resident care activities and care of indwelling devices. The policy also stated that EBP should be maintained for the duration of the resident’s stay or until the indwelling device is discontinued. CDC guidance reviewed by surveyors similarly indicated that EBP are recommended for residents with indwelling medical devices, even without known MDRO colonization or infection. Despite these clear policy and guidance requirements, the resident with a PEG tube was not placed on EBP, had no related orders or care plan interventions, and staff did not use gowns and gloves for high-contact care or PEG-related care, resulting in the cited deficiency.