Failure to Implement Enhanced Barrier Precautions for Residents with Catheters and Wounds
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling urinary catheters. Specifically, three residents with either suprapubic catheters or open wounds did not have EBP signage in their rooms, and staff practices were inconsistent with EBP protocols. For example, one resident with a suprapubic catheter reported that staff only wore gloves when handling the catheter but never wore gowns, and there was no EBP signage present in the room. Another resident with a stage III coccyx ulceration and drainage also lacked EBP signage, despite ongoing wound care and offloading measures documented in the medical record. Interviews with staff, including the DON, MDS Coordinator, CNA, and Infection Preventionist, revealed inconsistent understanding and implementation of EBP. While some staff stated they would wear gowns when emptying catheters, others only used gloves for certain care activities. The Infection Preventionist acknowledged that EBP should be in place for residents with urinary catheters or open wounds and that signage should be posted, but this was not consistently done. These findings were based on direct observation, interviews, and record review.