Failure to Implement Enhanced Barrier Precautions and Proper Urinary Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP) and urinary catheter care practices, for residents with internal urinary drainage devices. For one resident with obstructive uropathy requiring an internal urine drainage device, surveyors observed the urinary drainage bag dragging on the floor while the resident propelled in a wheelchair down the hall and later resting on the ground beneath the wheelchair during an activity in the dining room. This occurred despite the resident’s care plan directing staff to avoid allowing tubing or any part of the drainage system to touch the floor and documenting the need for EBP, including teaching the resident and staff about the chain of infection, methods of transmission, and principles of infection control. Another resident with a flaccid neuropathic bladder and an internal urine drainage device was observed in the dining room with the urinary drainage bag hanging beneath the wheelchair and resting on the ground, contrary to the care plan instructions that no part of the drainage system should touch the floor and that EBP would be used to reduce transmission of multidrug-resistant organisms. A third resident, alert and oriented with a long-term indwelling urinary catheter and on EBP, was found in bed with the catheter bag hanging from a garbage can and not in a dignity bag. A CNA emptied this resident’s catheter drainage bag without wearing any personal protective equipment (PPE), even though the resident’s status on EBP required PPE use. The DON later confirmed that urine drainage bags should never rest on the ground and that PPE should always be worn when a resident is on EBP, corroborating that these observed practices were inconsistent with facility policy and the residents’ care plans.
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