Failure to Implement Enhanced Barrier Precautions for Resident With Catheter and Drains
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling urinary catheter and multiple drains. During observation, the resident was found lying in bed with no EBP sign posted on the door and no PPE cart outside the room to indicate any type of isolation or precaution. An LPN at the bedside confirmed that the resident had a urinary catheter, a gallbladder drain, and a Jackson Pratt drain at the surgical site. The resident reported coming to the facility with two drains and a urinary catheter after a hospitalization for a severe infection that required a breathing tube, and stated she could not recall staff wearing gowns when handling her catheter or drains. The LPN later stated that the resident should have EBP in place due to the presence of the catheter and drains and that staff should be wearing gowns and gloves when providing direct care or handling the devices, but was unsure why the PPE cart was no longer outside the room. The DON also verified that there were no EBP measures in place for this resident and was similarly unsure why the sign and PPE cart were absent. Record review showed the resident was admitted with diagnoses including septic shock and had an order for dressing changes three times a week for the gallbladder drain, but there was no physician order for EBP. The facility’s EBP policy, dated 10/13/25, states that residents with indwelling urinary catheters or drains should be on EBP and that staff should wear gowns and gloves for direct care, with a PPE cart placed outside or near the resident’s room to identify the need for these precautions.
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