Failure to Implement Enhanced Barrier Precautions for Resident with Catheter and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one resident who required such measures due to the presence of an indwelling urinary catheter and ongoing wound care. According to the facility's policy and CDC guidelines, EBP—including the use of isolation gowns and gloves during high-contact care activities—are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Observations revealed that the resident's room did not have the required signage to alert staff and visitors of EBP requirements, despite the resident having both a catheter and wounds that necessitated these precautions. Interviews with the Director of Nursing confirmed that the resident's room lacked EBP signage and that the clinical record did not contain physician orders for EBP. The resident's medical history included an amputation of the left foot, diabetes, high blood pressure, and a coccyx wound, all of which increased the need for strict infection control measures. The failure to implement EBP as outlined in policy and regulatory requirements constituted a deficiency in the facility's infection prevention and control program.