Failure to Communicate and Implement Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were aware of and implemented Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and/or MDRO history, as required by the facility’s own policy. The EBP policy stated that an order for EBP would be obtained for residents with wounds or indwelling medical devices and that the facility would ensure staff were aware of which residents required EBP prior to providing high-contact care. However, for one resident with an indwelling catheter, there was no physician order for EBP or special instructions in the clinical physician orders, and no signage in the room to indicate EBP status. Surveyors identified three residents with indwelling urinary catheters who should have been on EBP but lacked appropriate communication measures. One resident with chronic kidney disease and an indwelling catheter had catheter tubing visible at the base of the pant leg, yet there was no EBP signage in the room, and a registered nurse who entered to connect portable oxygen stated he was not aware the resident was on EBP and did not know if PPE should have been used. Another resident with neuromuscular bladder dysfunction and an indwelling catheter had clinical orders noting a history of MRSA and EBP, but there was no signage in the room to indicate EBP. A third resident with urinary retention and an indwelling catheter also had special instructions for EBP in the clinical orders, but no EBP signage was observed in the room. Staff interviews and document reviews showed that frontline staff did not have a reliable method to identify which residents were on EBP. A CNA stated that EBP information was on the assignment sheet, but the posted assignment sheet only listed staff and their assigned areas and did not indicate EBP status. Another CNA reported that EBP information was communicated “pretty much vocal” and that she was not notified of any residents on EBP when receiving her assignment. An LPN stated that EBP information was on the Kardex in yellow binders on the back of residents’ doors, but review of the Kardexes for the three residents showed no mention of EBP despite their indwelling catheters. The DON acknowledged that residents who should be on EBP did not have signage or postings and that she was aware of what staff had reported about the location and communication of EBP information.
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