Failure to Implement and Communicate Enhanced Barrier Precautions and Proper Device Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents who required enhanced barrier precautions (EBP) or had indwelling devices. One resident with a Foley catheter did not have a sign posted at the room entrance indicating the need for EBP, despite the care plan specifying this intervention. Staff interviews confirmed that the resident was on EBP and that signage was required, but the sign was not present during observation. Another resident with a Foley catheter was observed with the catheter tubing touching the floor while sitting in a wheelchair at the nurse's station. The care plan for this resident included an intervention to keep the drainage bag off the floor, but this was not followed. Staff acknowledged that catheter tubing should not touch the floor and that all nursing staff were responsible for ensuring proper catheter care to prevent infection. A third resident with a gastric tube also did not have an EBP sign posted at the room entrance, although the care plan required it. PPE supplies were present outside the room, but staff were unsure about the responsibility for posting EBP signs. Interviews with staff and the administrator confirmed the importance of EBP signage and proper catheter care, and that training had been provided, but the required practices were not consistently implemented.