Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during PEG tube care. Resident #7 had a care plan focus initiated on 05/09/25 indicating risk of infection due to the presence of a PEG tube and specifying that EBP was to be utilized when providing care. The facility’s EBP policy dated 04/29/24 required donning gown and gloves during high-contact resident care activities for residents with indwelling medical devices, including feeding tubes, and a sign on Resident #7’s door indicated the resident was on EBP. On 02/23/26 at 9:20 a.m., LPN #1 was observed providing PEG tube care to Resident #7 without wearing a gown, contrary to the posted EBP sign, the resident’s care plan, and the facility’s EBP policy. During interview at 9:25 a.m., LPN #1 acknowledged they should have worn a gown while providing PEG tube care, and on 02/24/26 at 3:35 p.m., the infection preventionist confirmed that gowns were to be used when providing care to residents on EBP. The infection preventionist identified that 23 residents in the facility were on EBP.
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