Failure to Use Enhanced Barrier Precautions for PEG Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) policy for a resident with a percutaneous endoscopic gastrostomy (PEG) feeding tube. The resident, who had severely impaired cognition, a feeding tube, and a diagnosis of transient ischemic attack, was observed in a room without EBP signage and without readily accessible personal protective equipment. Facility policy dated 04/01/25 specified that residents with indwelling medical devices, including feeding tubes, required EBP, with staff wearing a gown and gloves for feeding tube care or use. The treatment administration record for the resident for the month of February did not include any order for enhanced barrier precautions. On multiple observed occasions, licensed nursing staff did not follow the EBP requirements while providing PEG tube-related care to this resident. An LPN checked PEG tube residuals and flushed the tube using only hand hygiene and gloves, without donning a gown. On two separate occasions, an RN checked residuals, administered scheduled medications and feeding via the PEG tube, and later performed a dressing change to the PEG tube site, each time wearing gloves but not a gown. The DON confirmed that enhanced barrier precautions, including gown and gloves, should have been used for this resident during direct care, PEG tube feeding, and medication administration, and the RN acknowledged failing to wear a gown during these procedures.
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.