Failure to Provide PPE and Enhanced Barrier Precaution Signage for Resident With Indwelling Catheter
Penalty
Summary
The facility failed to implement its infection prevention and control program by not providing required personal protective equipment (PPE) and signage for a resident who met criteria for enhanced barrier precautions (EBP). The facility’s March 2024 policy on Enhanced Barrier Precautions states that EBP are indicated, when contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organism (MDRO) colonization status, and that signs must be posted on the door or wall outside the resident room indicating the type of precautions and PPE required, with PPE available outside resident rooms. During an observation on February 4, 2026, at approximately 12:05 p.m., a resident identified as having an indwelling urinary catheter was observed without any EBP signage on or outside the room and with no PPE available in the room. Two LPNs confirmed the lack of required signage later that afternoon, and these findings were reported to the Nursing Home Administrator and Director of Nursing the same day. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services. The resident involved had an indwelling urinary catheter, defined in the report as a flexible tube inserted into the bladder to continuously drain urine into an external bag, which under facility policy required EBP when contact precautions did not otherwise apply. Despite this condition and the clear policy requirements, there was no posted indication of EBP or required PPE and no PPE available as specified by the policy at the time of the surveyor’s observation.
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