Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling urinary catheters. Surveyor observations revealed that residents with open wounds and a urinary catheter did not have the required EBP signage posted on their room doors, as mandated by facility policy and CDC guidance. Record reviews confirmed that these residents had physician orders for wound care and catheter management, which should have triggered EBP implementation, including the use of gowns and gloves during high-contact care activities. Interviews with nursing assistants and the unit manager indicated a lack of awareness and training regarding EBP requirements. Staff members providing direct care to affected residents were unaware that EBP and PPE use were necessary, and the unit manager acknowledged the absence of appropriate signage. The clinical market advisor also confirmed the expectation that residents with wounds or indwelling devices should be on EBP, with staff utilizing PPE during care. These findings demonstrate that the facility did not follow its own procedures or ensure staff competency in infection control practices for residents at increased risk of infection.