Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. Facility policy required the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling devices, regardless of known infection status. However, observations revealed that staff did not consistently follow these precautions, as evidenced by two CNAs providing direct care to a resident on EBP without donning the required personal protective equipment (PPE). Interviews with various staff members, including CNAs, a hydration aide, and an LPN, indicated confusion and lack of clarity regarding the identification and differentiation between EBP and contact precautions. Staff relied on visual cues such as yellow dots or supply bags outside resident rooms but were unsure of the specific requirements or which residents were on which precautions. Some staff admitted to forgetting to use PPE or not paying attention to precaution indicators, despite having received training on infection control and PPE use. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, emphysema, acute respiratory failure with hypoxia, and a urinary tract infection, and was assessed to have moderate cognitive impairment. The facility's infection preventionist and DON confirmed that audits and training were in place, but staff interviews and direct observation demonstrated lapses in adherence to EBP protocols, resulting in a failure to prevent potential transmission of communicable diseases and infections.