Failure to Implement Enhanced Barrier Precautions for Dialysis Residents with Central Lines
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program consistent with CDC guidance and its own policy regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, specifically central venous catheters (CVCs) used for dialysis. CDC guidance dated June 28, 2024, states that EBP, including gown and glove use during high-contact resident care activities, should be implemented for residents with wounds or indwelling medical devices such as central lines, and that these precautions should remain in place for the duration of the device. The facility’s written EBP policy acknowledges that indwelling medical devices include central lines, but further review showed the facility does not place residents on EBP when they have a central line for dialysis, which is not aligned with CDC guidance. For one resident admitted in December 2021 with end stage renal disease and dependent on in-house dialysis three times weekly, physician orders included monitoring the right chest CVC access site every shift for signs of infection and documenting abnormal findings, but there was no order for EBP despite the presence of the indwelling CVC. Surveyor observation of this resident’s room showed EBP signage and a PPE bin at the entrance, but the Regional Director of Clinical Services stopped the surveyor from donning PPE and stated the resident did not require EBP, explaining the signage and bin were placed in anticipation of a new admission. For a second resident admitted in June 2025 with Parkinson’s disease and dependent on in-house dialysis three times weekly, orders included monitoring the right chest CVC site and dressing every shift, but again there was no EBP order. In an interview, the Regional Director of Clinical Services confirmed that the facility does not follow EBP for residents with a CVC for dialysis, despite acknowledging CDC’s recommendation for EBP for residents with indwelling medical devices, including central lines.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.