Failure to Use PPE During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff used appropriate personal protective equipment (PPE) during medication administration via a percutaneous endoscopic gastrostomy (PEG) tube. A resident admitted with a diagnosis of gastrostomy status and documented on the MDS as receiving nutrition through a feeding tube was observed receiving medications through the PEG tube from an LPN who did not wear any PPE. At the time of the observation, there was no signage on the resident’s door indicating the use of Enhanced Barrier Precautions (EBP). During an interview, the LPN stated she believed PPE was only required when providing treatments such as cleaning the PEG tube area and acknowledged she should have worn PPE during PEG tube medication administration. In a subsequent interview, the Infection Preventionist and the DON confirmed that staff are required to wear PPE when administering medications to residents with PEG tubes and that staff had been trained on this requirement, including at a recent skills fair. Review of the facility’s policy on Enhanced Barrier Precautions and Isolation Procedures indicated that the facility is to use Standard Precautions, EBP, and Transmission-Based Precautions as clinically indicated to prevent and control infectious disease, including MDROs.
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