Failure to Follow Enhanced Barrier Precautions and Refrigerator Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to properly implement its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling device and to consistently monitor a resident’s personal refrigerator temperature. The facility’s EBP policy dated 8/15/25 required staff to don both gloves and a gown before initiating high-contact activities with high-risk residents, such as those with indwelling devices, and to remove personal protective equipment before exiting the room. Resident R12, admitted on an unspecified date, had diagnoses including diabetes, stroke, and seizure disorder, and the MDS dated 2/9/26 documented the presence of a feeding tube. A physician’s order dated 1/11/26 indicated that EBP were required for this resident. On 3/30/26 at 10:00 a.m., an LPN (Employee E1) was observed wearing gloves while hanging a new bag of tube feeding supplement via pump to the resident’s gastrostomy tube, a high-contact activity, but failed to wear a gown as required by the EBP policy. In a subsequent interview, the LPN confirmed not wearing a gown during this high-contact activity. The deficiency also includes failure to follow the facility’s Freezers and Refrigerators Policy dated 8/15/25, which required monthly tracking sheets for all refrigerators and freezers to record temperatures between 35 and 41 degrees. Resident R44, admitted on an unspecified date, had a personal refrigerator in the room with a temperature log posted on the outside. On 3/30/26 at 9:16 a.m., observation revealed that the log had the month and year fields left blank and that fifteen of thirty days on the log were not completed. In an interview at 9:30 a.m., an RN (Employee E2) confirmed the missing month and year and the fifteen blank days on the temperature log. Later that day, the Director of Nursing confirmed that the facility failed to ensure EBP were properly managed for Resident R12 and failed to properly monitor the personal refrigerator temperature for Resident R44, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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