Failure to Use Required PPE During Enhanced Barrier Precautions for Tracheostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) requirements, for a resident with multiple indwelling devices. The resident was an older female with anoxic brain damage, dementia, severely impaired cognitive skills, impaired upper and lower extremities, and total dependence on staff for all ADLs and bed mobility. She had a tracheostomy, an indwelling urinary catheter, and a feeding tube, and received tracheostomy care, oxygen therapy, and suctioning. Her physician orders included EBP every shift and daily/prn trach tie changes, and her comprehensive care plan documented that she required EBP related to her feeding tube and tracheostomy. A sign posted outside her room indicated she was on EBP and listed device care for a tracheostomy as a high-contact resident care activity requiring gown and gloves. During an observation, an LVN entered the resident’s room to perform tracheostomy care. The LVN donned gloves, removed the oxygen mask from the resident’s tracheostomy, and attached a new oxygen mask, but did not wear a gown despite the EBP sign and the resident’s EBP orders. In an interview, the LVN acknowledged that residents with Foley catheters, infections, or tracheostomies were on EBP and were identified by a sign outside the doorway, but stated that when caring for residents on EBP, staff were supposed to wear gloves and “maybe” gowns, depending on the situation, and that she did not think a gown was needed for tracheostomy care. The DON stated that residents with indwelling devices such as tracheostomies would be on EBP and that staff were expected to wear a gown and gloves when providing direct care to such residents. The facility’s EBP policy and the posted sign both specified that gown and glove use was required for high-contact activities including device care for tracheostomies, indicating that the observed care did not comply with facility policy and the resident’s EBP orders.
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