Failure to Follow Enhanced Barrier Precautions and Proper Catheter Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines for multiple residents, specifically regarding the use of Enhanced Barrier Precautions (EBP) and the management of urinary catheter tubing and drainage bags. For several residents with pressure wounds and orders for EBP, staff, including a nurse practitioner and a licensed practical nurse, entered rooms and provided wound care without donning required gowns, despite clear signage and available supplies indicating the need for gowns and gloves during high-contact care activities. This was observed on multiple occasions for residents with cognitive impairments and complex medical histories, including stroke, depression, obesity, quadriplegia, and pressure ulcers. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with her catheter bag and tubing dragging on the floor while propelling herself in her wheelchair. The resident reported that staff consistently placed the catheter bag under her wheelchair, resulting in the bag and tubing coming into contact with the floor. The resident had a recent history of urinary tract infection, and observations confirmed that the catheter bag and tubing were not properly managed, with cloudy urine and sediment noted in the tubing. The facility's own policy emphasized the importance of proper catheter care to prevent catheter-associated urinary tract infections. Facility policies for both EBP and catheter care were available and provided by facility leadership, outlining the need for appropriate use of personal protective equipment and proper catheter management. Despite these policies, staff did not adhere to the required infection control practices during direct care activities, as confirmed by both observation and staff interviews.