F0880

D

Noncompliance With Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters

Carmichael, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to follow the facility’s infection prevention and control practices, specifically enhanced barrier precautions, for residents with indwelling urinary catheters. Resident 1, admitted with urinary retention and a personal history of infectious disease, had a care plan requiring enhanced standard/barrier precautions, including changing gowns and gloves and performing hand hygiene when moving from contact with one resident to another. During observation, CNA 1 adjusted Resident 1’s urine drainage bag, then removed his gloves, went to another room to obtain new gloves, and proceeded to provide care to another resident without performing hand hygiene in between. In a subsequent interview, CNA 1 acknowledged that he should have washed his hands before putting on new gloves.

Resident 2, re-admitted after hospitalization for sepsis, urinary tract infection, and acute kidney failure, also had a care plan requiring enhanced barrier precautions, including wearing gowns and gloves for device care such as urinary catheter care. During observation, CNA 2 adjusted Resident 2’s urine drainage bag without wearing gloves. In an interview, CNA 2 confirmed she did not wear gloves and stated she should have worn them. Review of the facility’s enhanced barrier precautions policy showed that residents with indwelling medical devices, including urinary catheters, were to be on enhanced barrier precautions, and staff were required to wear gowns and gloves and perform hand hygiene between residents. The Infection Preventionist Nurse and the Assistant Director of Nursing both stated that staff were required to wear PPE and perform hand hygiene for residents on enhanced barrier precautions.