Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter, as observed during a survey. On April 1st, Resident #33 was seen with a catheter connected to the side of the bed without any signage indicating the need for EBP. The facility's Infection Control and Isolation Policy, revised in March 2024, mandates EBP for residents with indwelling medical devices, such as urinary catheters, even if they are not known to be infected or colonized with a multi-drug resistant organism. Despite this policy, the necessary precautions were not in place for Resident #33, who had a diagnosis of obstructive and reflux uropathy and an intact cognition with a BIMS score of 15. The resident's care plan, dated March 3rd, included specific instructions for catheter care, but did not mention EBP. A physician order for EBP was only documented on April 2nd, after the surveyor's observation. Interviews with staff revealed that the certified medication aide and the resident themselves confirmed the absence of EBP, with the resident noting that staff did not use a gown when emptying the catheter. An LPN reported that they requested the EBP order on April 2nd, acknowledging that EBP should have been in place since the catheter was inserted on March 3rd.