Failure to Follow Enhanced Barrier Precautions and Prevent Cross-Contamination
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols for a resident on CDC Enhanced Barrier Precautions (EBP) who had a chronic indwelling urinary catheter and a recent history of urinary tract infection with multi-drug-resistant organisms. During high-contact care activities, such as transferring the resident from bed to wheelchair, a Certified Nursing Assistant did not wear the required isolation gown and gloves, despite signage and facility policy indicating the necessity of personal protective equipment (PPE) for such tasks. Multiple staff interviews confirmed that PPE should be used during high-contact care and catheter care, but this was not consistently practiced. Additionally, the resident’s urinary drainage bag and tubing were observed in direct contact with the floor on more than one occasion, both in the resident’s room and in the dining area. Staff did not address the contamination risk, and it was noted that the privacy bag used to contain the catheter sometimes failed to keep the drainage bag off the floor as intended. Facility policy required that urinary drainage bags be covered and kept off the floor at all times, but this was not followed, resulting in a failure to prevent cross-contamination.