Failure to Follow Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Infection Prevention and Control Program and Enhanced Barrier Precautions (EBP) policy during care of a resident with an indwelling central line. The resident was an elderly female with a history of cerebral infarction, right-sided hemiplegia/hemiparesis, and dementia, who had been admitted and readmitted to the facility and was receiving IV medications. Her orders included EBP with PPE required for high resident contact activities due to an implanted IV access, with a start date of 02/21/26. Facility policy on IPCP and EBP required the use of gown and gloves for high-contact resident care activities, including device care for central vascular lines. On 02/23/26 at 9:35 AM, during direct observation, LVN A flushed the resident’s central line with normal saline without wearing a gown, despite a PPE box and an EBP sign posted outside the resident’s room. During interview, LVN A acknowledged she should have worn a gown when flushing the central line, stated she was not thinking about it and forgot, and confirmed she had last received EBP training around October 2025, with her signature documented on a facility EBP education form dated 12/17/25. The DON and ADM both stated they expected staff to follow EBP for residents on such precautions and identified that the facility had signage and PPE boxes available. The facility’s written policies specified that personnel must conduct care in a way that minimizes the spread of infection and that gown and gloves are required for high-contact activities involving indwelling devices such as central lines.
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