Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident with an indwelling catheter. Observations revealed that there was no Enhanced Barrier Precautions (EBP) signage posted on the resident's door or room, and no personal protective equipment (PPE) cart was available outside the door, despite the resident having a permcath for dialysis and an indwelling Foley catheter. Interviews with staff, including a CNA, LVN, and the DON, confirmed that facility policy required EBP signage and PPE for residents with indwelling medical devices, but these measures were not in place for this resident. Staff acknowledged the absence of required signage and PPE, and indicated that this was not in accordance with facility policy. Record reviews showed that the resident had multiple diagnoses, including type 2 diabetes, hypertension, and irritable bowel syndrome, and required assistance with personal care. The care plan documented the presence of an indwelling catheter and outlined interventions for its management. Despite these documented needs and the facility's infection control policy, the required EBP measures were not implemented for this resident, and staff were unable to provide a reason for the omission, with the DON suggesting a possible miscommunication due to a recent room transfer.