Failure to Implement Enhanced Barrier Precautions During Resident Transfers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as required by physician orders and the facility's own infection control policy. The resident had multiple diagnoses, including dementia, urinary tract infection, neuromuscular bladder dysfunction, and was dependent on staff for all functional abilities and mobility. The care plan and physician orders specified the use of gowns and gloves during high-contact care activities and directed the use of EBP due to the resident's increased risk for healthcare-acquired infections. Despite these directives, staff used a full-body mechanical lift and shared sling to transfer the resident, and the same sling was also used for two other residents. Observations confirmed that staff donned disposable gloves and gowns during high-contact care, but failed to ensure single-resident use of the lift sling for the resident with an indwelling catheter. The facility's policy emphasized the importance of targeted PPE use and adherence to CDC recommendations to prevent the transmission of multidrug-resistant organisms (MDROs). The shared use of the lift sling, contrary to the care plan and infection control protocols, constituted a failure to fully implement EBP and placed residents at risk for infectious disease transmission.