Failure to Implement Enhanced Barrier Precautions and Signage for Residents with Wounds and Indwelling Devices
Penalty
Summary
Surveyors identified a failure to maintain proper infection prevention and control measures related to Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) for three residents. One resident with multiple pressure ulcers, including two stage 3 pressure ulcers, one stage 4 pressure ulcer, one unstageable pressure ulcer due to a non-removable dressing or device, and one unstageable pressure ulcer/injury presenting as deep tissue injury, did not have an EBP sign posted at the entry of the room during observation. Another resident receiving enteral feeding via a gastrostomy tube also did not have an EBP sign posted at the room entrance. In both of these cases, PPE was noted as being readily available at the entry to the rooms, but the required EBP signage was missing. A third resident with a physician order for EBP due to the presence of a Foley catheter likewise did not have an EBP sign posted at the room entrance during observation. A CNA confirmed that there was no EBP sign posted for this resident. In an interview, the DON confirmed that residents with pressure ulcers, enteral feeding tubes, and Foley catheters require EBP signs posted outside their rooms with PPE available for staff, and stated that her expectation is that residents with open wounds or indwelling devices should have precautions in place and followed. The observations and interviews demonstrated that EBP signage was not consistently posted as required for these residents, despite the facility’s stated expectations.
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