F0880

D

Failure to Follow Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters

Rochelle, Illinois Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program by not following enhanced barrier precautions (EBP) and proper catheter handling for residents with indwelling urinary catheters. One resident with an indwelling urinary catheter and a history of urinary tract infections, colonized ESBL in the urine, and multiple comorbidities including Alzheimer disease and morbid obesity was observed sitting in the dining room with an uncovered catheter drainage bag under the wheelchair, dragging on and touching the floor. A RN moved the resident’s wheelchair without noticing the drainage bag on the floor, and when it was pointed out, the RN and a CNA attempted to adjust the drainage bag without wearing any PPE, despite the resident’s care plan indicating EBP due to colonized ESBL and the facility policy requiring gown and gloves for high-contact care involving indwelling devices.

In a separate incident, another resident with an indwelling urinary catheter and multiple diagnoses including congestive heart failure, deep venous thrombosis, urinary tract infection, and obesity was observed in her room while a RN, wearing only gloves, aspirated urine from the catheter tubing using a syringe. The RN had clamped the catheter tubing distally to prevent drainage into the bag and was unsure whether the resident was on EBP, even though there was an EBP sign on the resident’s door and the care plan documented enhanced barrier precautions per facility protocol. The ADON confirmed that EBP required gown and gloves when handling catheters, consistent with the facility’s EBP policy stating that residents with indwelling medical devices, including urinary catheters, require targeted gown and glove use during high-contact care activities.