Failure to Implement Infection Control Precautions and Proper Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for three residents, resulting in lapses in the implementation of Enhanced Barrier Precautions (EBP) and proper catheter care. For one resident with liver disease, immune system defects, and an unstageable pressure ulcer, there was no isolation signage or PPE at the room entrance upon admission, despite the presence of an open wound and orders for wound management. Staff interviews confirmed that EBP should have been implemented upon admission, but it was delayed until after the wound nurse practitioner identified drainage, and the infection preventionist and DON acknowledged the delay was unacceptable. Another resident with a history of benign prostatic hyperplasia, peripheral vascular disease, hypertension, and chronic kidney disease, and who was cognitively intact, was observed multiple times with a Foley catheter bag placed directly on the floor without a dignity cover. Despite repeated staff education and interventions to keep the catheter bag off the floor, the resident continued to place it there, and there was no documentation of education or care plan interventions addressing this behavior. Staff interviews confirmed awareness of the issue and the infection control risks, but no formal documentation or care plan adjustments were made. A third resident with congestive heart failure, COPD, diabetes, and a history of a deep tissue injury and unstageable wound to the left heel, was not placed on EBP when the wound became open. Observations revealed a lack of EBP signage and PPE at the room, and staff only implemented precautions after being notified by the wound nurse practitioner. The infection preventionist and DON both stated that EBP should have been initiated when the wound opened, and that the delay in implementing precautions was not in line with facility expectations for infection control.