Failure to Implement Enhanced Barrier Precautions and Proper Urinary Catheter Bag Positioning
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its infection prevention and control program for residents on enhanced barrier precautions and for residents with urinary catheters. One resident with Parkinson’s disease, dementia, bipolar disorder, and a surgical wound had a care plan indicating the need for enhanced barrier precautions during high-contact care due to the presence of a surgical incision. Observation showed bins of PPE in the resident’s room but no signage outside the door to indicate enhanced barrier precautions. The resident did not understand why the bins were present. An LPN initially stated the resident was not in isolation and was unaware of any such precautions until reviewing the orders with the surveyor, at which point the LPN confirmed the resident was on enhanced barrier precautions and that no signage was in place. A regional nurse also verified that enhanced barrier precaution orders were in place without corresponding signage. A second resident with type 2 diabetes mellitus, metabolic encephalopathy, urogenital implants, hydronephrosis, and a neurogenic bladder managed with a urinary catheter was observed multiple times with the urinary catheter bag on the floor. During an activity in the dining room, the catheter bag was lodged under the small front wheel of the wheelchair. An LPN confirmed this and then repositioned the bag so that half of it remained touching the floor under the wheelchair, stating there was no feasible way to hang the bag below the bladder and off the floor due to the wheelchair’s low height. A later observation at the nurses’ desk again showed the catheter bag lying on the floor under the wheelchair. The manufacturer’s label for the catheter bag specified that the bag should not be on the floor, and the facility’s policy on emptying urinary bags required that urinary catheter bags be kept off the floor to prevent damage and contamination.
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