Failure to Maintain Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents. For one resident, a female with dysphagia, diabetes, chronic kidney disease, cognitive communication deficit, and muscle weakness, records showed she used a PureWick urinary system and was care planned as having a PURE WICK urinary system and being at risk for UTI, with interventions including catheter care and monitoring urine. She was also on Enhanced Barrier Precautions per signage at her room. During observation, her PureWick catheter was seen on a pad to the right of the bed with the tubing touching the floor. A CNA assigned to her care and the LVN overseeing her hall both acknowledged that the PureWick tubing should not be on the floor and identified this as an infection control issue and a risk of contamination. The DON stated catheter tubing should not be on the floor due to the risk of bacteria on the outside of the tube. The facility also failed to implement Enhanced Barrier Precautions (EBP) correctly for two other residents with wounds. One male resident with chronic kidney disease, urinary retention, dysphagia, and an unhealed pressure injury/ulcer had orders for heel protectors due to multiple unstageable wounds. Another resident also had wounds. The facility’s Enhanced Barrier Precautions Program, revised March 2024, stated that EBPs are indicated for residents with wounds and/or indwelling medical devices, including chronic wounds such as pressure ulcers and urinary catheters. However, observations showed that these two residents did not have EBP signage or supplies (such as a cart) by their doors. Nursing staff, including LVNs and the DON, stated that residents with wounds or indwelling catheters should be on EBP, that staff rely on signage and carts to know a resident is on EBP, and that lack of EBP or signage could result in cross contamination, spread of infectious diseases, or wound infections.
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