Failure to Implement Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by both the resident's care plan and facility policy. During a transfer of the resident to bed using a mechanical lift, an LPN wore gloves but did not wear a gown, and a CNA wore neither gloves nor a gown. Personal protective equipment, including gowns and gloves, was available in the resident's room, but was not utilized as required during the high-contact care activity. The CNA later confirmed in an interview that staff should have been wearing a gown and gloves during the transfer. The resident involved had a diagnosis of obstructive uropathy and a documented indwelling urinary catheter, placing them at increased risk for colonization or infection with multi-drug resistant organisms. The care plan specifically identified the need for enhanced barrier precautions, including the use of gown and gloves during transfers. The facility's current policy, provided by the Director of Nursing, also required staff to wear gown and gloves for residents with indwelling urinary catheters during transfers, but this protocol was not followed during the observed event.