Failure to Implement Infection Control Precautions for Residents with Indwelling Catheters
Penalty
Summary
Surveyors found that the facility failed to implement and maintain an effective infection prevention and control program for residents with indwelling Foley catheters. Observations revealed that multiple resident rooms lacked required signage indicating the type of precautions and necessary PPE, as recommended by CDC guidance for Enhanced Barrier Precautions. In several cases, there was no PPE available outside the resident rooms, and signage was either missing, improperly placed, or not visible at the entrance. These deficiencies were confirmed by the Quality Improvement Specialist during the survey. Additionally, interviews with staff, including the Director of Nursing and Infection Preventionist, revealed a lack of awareness regarding the location of reference materials and the current status of residents on transmission-based precautions. Record review showed that residents with indwelling catheters, including those with active infections such as urinary tract infections caused by multidrug-resistant organisms, were not placed on appropriate contact precautions as required by facility policy and CDC guidelines. Staff interviews indicated that frontline caregivers were not informed about residents' precaution status, and there was confusion among leadership regarding the implementation of infection control protocols. These findings were based on direct observation, record review, and staff interviews, demonstrating a failure to follow established infection control policies for residents at risk of transmitting infectious diseases.