Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The facility’s policy, revised in 03/2024, states that EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO), including device care or use such as central lines and ports. Resident #95’s clinical record showed an order to implement and maintain EBP during high-contact care starting 11/19/2025, an order allowing access to a port dated 08/24/2023, and an order for daily IV Vancomycin for a sacral wound infection dated 01/02/2026. An EBP sign was posted on the resident’s door, instructing that staff must wear gloves and a gown for high-contact activities including device care or use. On 01/13/2026 at 1:02 p.m., a surveyor observed an LPN (S4LPN) administering IV Vancomycin via the resident’s right chest port without wearing a gown, despite the EBP signage and the resident’s active EBP orders related to his port and wounds. During an interview immediately afterward, the LPN confirmed that the resident was on EBP due to his port and wounds and acknowledged that she should have worn a gown while providing direct resident care but did not. Later, the DON (S2DON) stated that when a resident is on EBP, he expected staff to wear appropriate PPE when providing direct resident care, confirmed that EBP is initiated for residents with indwelling medical devices such as a port, and further confirmed that appropriate PPE should be worn during IV medication administration through a port.
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