DUBOIS, PA - Federal health inspectors cited Dubois Nursing Home at 212 S. Eighth St. for multiple deficiencies during a June 2024 survey, including a failure to implement proper infection prevention and control measures for a resident with a history of multidrug-resistant organisms (MDROs) and an indwelling catheter.
Staff Observed Without Required Protective Equipment
During the inspection on June 24, 2024, surveyors observed a nurse aide emptying a catheterized resident's drainage bag while wearing gloves but no protective gown — a direct violation of the facility's own care plan and physician's orders for enhanced barrier precautions (EBP).
The resident, identified in the inspection report as Resident 17, had a urinary catheter in place and a documented history of MDRO colonization. Both conditions independently require the use of enhanced barrier precautions under current federal infection control guidelines. The resident's care plan, dated April 30, 2024, specifically noted that EBP were in place due to the MDRO history and catheter placement. A physician's order from May 1, 2024, further directed staff to observe enhanced barrier precautions every shift.
Despite these clear directives, when surveyors observed Nurse Aide 7 at 12:47 p.m. draining what was described as tea-colored urine from the catheter bag into a cylinder, the aide was not wearing a gown. Signage at the entrance to the resident's room indicated that infection control measures were in place — yet the posted protocols were not being followed.
When interviewed at the time of the observation, the nurse aide stated that she believed a gown was only necessary "when providing care," apparently not recognizing that emptying a catheter drainage bag constitutes a high-contact care activity under current guidelines.
Why Enhanced Barrier Precautions Exist
Enhanced barrier precautions represent a relatively new tier of infection control measures that the Centers for Disease Control and Prevention (CDC) developed specifically for skilled nursing facilities. Unlike standard contact precautions — which typically require gowns and gloves for all interactions with an isolated patient — EBP takes a more targeted approach, requiring gowns and gloves during high-contact care activities such as dressing, bathing, wound care, and handling medical devices like catheters.
The CDC issued its guidance on EBP implementation in nursing homes in July 2022, and the Centers for Medicare & Medicaid Services (CMS) updated its infection prevention requirements effective April 1, 2024 — just two months before this inspection took place. The updated CMS guidance expanded the use of EBP to include all residents with chronic wounds or indwelling medical devices, regardless of whether they have a known MDRO, in addition to those with confirmed MDRO infections or colonization.
Multidrug-resistant organisms are bacteria that have developed resistance to multiple antibiotics, making infections significantly harder to treat. MRSA, VRE, and certain drug-resistant gram-negative bacteria are among the most common MDROs found in nursing home settings. When these organisms spread between residents — often through the hands or clothing of healthcare workers — the consequences can be severe, particularly for elderly individuals with compromised immune systems.
Catheterized residents face an elevated baseline risk of infection. Urinary catheters create a direct pathway for bacteria to enter the bladder, and catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections in long-term care settings. When a catheterized resident also carries an MDRO, the potential consequences of cross-contamination become more serious, as any resulting infection may not respond to first-line antibiotic treatment.
What Should Have Happened
According to established infection control protocols, any staff member performing a high-contact care activity with Resident 17 should have donned both gloves and a disposable isolation gown before beginning the task. Emptying a catheter drainage bag involves direct contact with a medical device and bodily fluids, placing it squarely within the definition of a high-contact care activity under CDC guidelines.
The proper procedure for emptying a catheter bag requires the healthcare worker to:
- Perform hand hygiene before entering the resident's room - Put on both a gown and gloves before touching the catheter or drainage system - Use a clean, graduated cylinder to collect the urine for measurement - Avoid allowing the drainage spigot to contact the collection container - Dispose of urine properly and clean the cylinder - Remove the gown and gloves in the correct sequence to avoid self-contamination - Perform hand hygiene again after removing personal protective equipment
The failure to gown during this procedure creates a risk that organisms present on the catheter system or in the urine could transfer to the aide's clothing. That clothing then becomes a potential vehicle for spreading organisms to other residents during subsequent care activities — the exact transmission pathway that enhanced barrier precautions are designed to interrupt.
Facility's Director of Nursing Confirmed the Violation
The facility's Director of Nursing, interviewed on June 27, 2024, at 1:18 p.m., confirmed that Resident 17 was on enhanced barrier precautions and that staff should have been wearing a gown when emptying the catheter bag. This acknowledgment indicates that facility leadership understood the requirements but that the protocols were not being consistently followed at the point of care.
The gap between written policy and actual practice is a recurring concern in nursing home infection control. Facilities may have appropriate care plans and physician orders in place, but if frontline staff are not adequately trained — or if compliance is not monitored — those written protections provide no real benefit to residents.
The nurse aide's stated belief that a gown was only required "when providing care" suggests a fundamental misunderstanding of what constitutes a high-contact care activity. This type of knowledge gap points to potential deficiencies in staff training and competency verification around the updated EBP requirements that took effect in April 2024.
Additional Deficiencies Identified
The infection control violation was classified under F-tag 880, which addresses a facility's obligation to provide and implement an infection prevention and control program. The deficiency was assessed at a level of minimal harm or potential for actual harm, affecting few residents.
Inspectors also cited the facility under F-tag 689 and F-tag 867 during the same survey. F-tag 689 relates to a facility's responsibility to ensure that residents receive adequate supervision and assistance to prevent accidents, while F-tag 867 addresses administration and management responsibilities including compliance with state licensure requirements under Pennsylvania Code.
The deficiencies referenced several sections of Pennsylvania state regulations, including 28 Pa. Code 201.14(a) regarding the responsibility of the licensee, 28 Pa. Code 201.18(e)(1) on management standards, and 28 Pa. Code 211.12(d)(1)(5) concerning nursing services.
The Broader Context of Infection Control in Nursing Homes
MDRO transmission in skilled nursing facilities remains a significant public health concern. Nursing home residents are particularly vulnerable due to advanced age, multiple chronic conditions, frequent antibiotic exposure, and close living quarters. The CDC has noted that MDRO transmission is common in skilled nursing settings and contributes to substantial resident morbidity, mortality, and increased healthcare costs.
The implementation of enhanced barrier precautions represented a shift in how the healthcare system approaches infection control in long-term care. Prior to EBP, facilities often had to choose between full contact precautions — which can be socially isolating for residents and resource-intensive for facilities — and standard precautions that may not adequately prevent MDRO spread. EBP was designed as a middle ground, targeting the specific care activities most likely to result in transmission.
For EBP to be effective, however, every staff member who performs high-contact care activities must understand when gowns and gloves are required and consistently follow the protocols. A single lapse, such as the one observed at Dubois Nursing Home, can compromise the entire system.
Families of residents at Dubois Nursing Home and other long-term care facilities can review complete inspection reports through the CMS Care Compare website or by contacting the Pennsylvania Department of Health. Understanding a facility's inspection history and deficiency patterns can provide valuable insight into the quality of care being delivered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2024-06-27 including all violations, facility responses, and corrective action plans.
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