BRADENTON, FL - Federal inspectors documented significant lapses in infection prevention protocols at Aviata at Palma Sola Bay, where two medically fragile residents with invasive medical devices remained without required enhanced barrier precautions for extended periods, potentially exposing them to life-threatening infections.
Missing Safety Protocols for Vulnerable Residents
During a July 2024 inspection, surveyors identified critical failures in the facility's infection control program affecting residents with serious medical conditions requiring intravenous therapy, feeding tubes, and urinary catheters. The violations centered on the absence of enhanced barrier precaution signage and protective equipment—fundamental safeguards designed to prevent the spread of multidrug-resistant organisms (MDROs) in healthcare settings.
One resident receiving treatment for endocarditis—a serious heart valve infection—through a peripherally inserted central catheter (PICC line) lacked the required precaution signage on multiple days. The resident's medical record documented ongoing antibiotic therapy scheduled to continue for six to eight weeks, yet the facility failed to implement basic protective measures from the time of admission.
Enhanced barrier precautions represent a critical defense against healthcare-associated infections, particularly for residents with indwelling medical devices. These protocols require healthcare workers providing direct care to wear gowns, gloves, and masks before entering the resident's room. The precautions exist because medical devices like IV lines, feeding tubes, and urinary catheters create direct pathways for bacteria to enter the body, bypassing the skin's natural protective barrier.
Cardiac Patient Left Without Infection Controls
The inspection revealed concerning gaps in protection for a resident admitted with multiple serious cardiovascular conditions, including endocarditis and an artificial heart valve. This resident required daily intravenous antibiotic administration through a PICC line inserted on June 21, 2024. Inspectors observed the resident on July 8 and again on July 11, finding no enhanced barrier precaution signage on the door and no storage bin containing personal protective equipment outside the room on either visit.
The facility's care plan, dated July 6, 2024, specifically documented that "the resident requires enhanced barrier precautions related to use of indwelling medical device IV PICC and is at risk for a CDC MDRO infection." The plan included an intervention for "signage at designated area to alert staff and visitor of enhanced barrier precautions" initiated on July 8, 2024. Despite this documentation, the required signage remained absent three days later during the follow-up inspection observation.
Endocarditis infections require prolonged intravenous antibiotic therapy because the heart valve tissue has limited blood supply, making it difficult for oral medications to reach therapeutic levels. The infection itself develops when bacteria enter the bloodstream and attach to damaged heart valves or artificial valve replacements. A PICC line, while medically necessary for extended IV therapy, creates an additional infection risk. Bacteria can travel along the catheter directly into the bloodstream, potentially seeding new infections in the already compromised heart valve.
The resident's medical record indicated physician orders for specialized catheter care, including dressing changes on admission and weekly thereafter, as well as flushing the PICC line with saline solution every shift. These maintenance procedures, while essential, also represent opportunities for bacterial contamination if healthcare workers don't follow proper protective protocols.
Quadriplegic Resident Without Protection for Multiple Devices
A second resident presented an even more complex situation involving multiple indwelling devices. This quadriplegic resident had been admitted to the facility on March 2, 2024, with a feeding tube, urinary catheter, and colostomy—three separate medical devices requiring enhanced precautions. The resident also had documented chronic wounds requiring dressings, methicillin-resistant staphylococcus aureus (MRSA) infection, and osteomyelitis, a serious bone infection affecting the vertebra.
Inspectors observed this resident's room on July 9 and July 11, 2024, finding no enhanced barrier precaution signage on either date. The facility didn't enter a physician order for enhanced precautions until July 9—more than four months after admission, despite the presence of multiple qualifying medical devices from day one.
The combination of medical devices in this resident's care created multiple potential entry points for infection. Feeding tubes bypass the mouth's natural bacteria-fighting mechanisms, allowing organisms to enter the digestive system directly. Urinary catheters provide a pathway for bacteria to reach the bladder and potentially the kidneys. Colostomies involve openings in the abdominal wall where intestinal contents exit the body, creating wounds that require careful management to prevent skin breakdown and bacterial contamination.
The resident's existing MRSA colonization made proper barrier precautions even more critical. MRSA represents one of the most concerning multidrug-resistant organisms in healthcare settings because it resists treatment with standard antibiotics. Without proper precautions, MRSA can spread from colonized residents to others through contaminated hands and equipment, potentially causing serious skin infections, pneumonia, bloodstream infections, and surgical site infections in vulnerable populations.
Systemic Failures in Infection Prevention Program
The inspection revealed not just isolated incidents but systemic problems in the facility's infection control program implementation. Staff interviews demonstrated that employees across disciplines—certified nursing assistants, housekeepers, physical therapy assistants, and licensed nurses—all understood they should look for signage on resident doors to determine what protective equipment to wear. As one nursing assistant stated, "If it says gown and mask, I put on gown and mask before going in the room."
However, the system depended entirely on the presence of that signage. When interviewed, the facility's infection preventionist acknowledged the failures, stating the enhanced precautions sign "should have been on the door" for the cardiac patient and admitting "that's my mistake" regarding the missing protection. For the resident with multiple devices, the infection preventionist acknowledged, "We didn't catch it."
The infection preventionist explained that enhanced precautions should automatically apply to any resident with indwelling medical devices such as urinary catheters, IV lines, feeding tubes, nephrostomy tubes, or wound vacuum devices. The facility maintained a matrix tracking 20 residents on enhanced barrier precautions, yet neither of the residents observed during the inspection appeared on that list despite clearly meeting the criteria.
The facility's own policy, dated August 2022, explicitly stated that "enhanced barrier precautions are indicated for resident with wounds and/or indwelling medical devices regardless of multidrug resistance organism colonization" and that "signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required."
Understanding the Medical Stakes
The documented failures carry significant medical implications beyond procedural compliance. Healthcare-associated infections represent a leading cause of morbidity and mortality in long-term care facilities. The Centers for Disease Control and Prevention estimates that between 1 million and 3 million serious infections occur in nursing homes annually, contributing to approximately 380,000 deaths.
Residents with indwelling medical devices face substantially elevated infection risks. Urinary catheters account for the majority of urinary tract infections in nursing homes, with bacteriuria developing in virtually all residents with long-term catheterization. These infections can progress to urosepsis, a life-threatening bloodstream infection with mortality rates approaching 20-40% in elderly populations.
Central venous catheters like PICC lines carry infection rates of 0.5 to 2.0 bloodstream infections per 1,000 catheter-days in skilled nursing facilities. For a resident with pre-existing endocarditis, a catheter-related bloodstream infection could prove catastrophic, potentially seeding new infections on already damaged heart valves or leading to septic emboli—infected blood clots that travel to vital organs.
Feeding tubes present their own infection challenges, particularly aspiration pneumonia when gastric contents enter the lungs. Proper infection control protocols help minimize bacterial contamination during tube care and feeding administration, reducing the risk of introducing pathogens that could cause pneumonia, particularly in residents with compromised immune systems or swallowing difficulties.
Additional Issues Identified
Beyond the primary infection control failures, the inspection revealed related concerns about the facility's oversight systems. The absence of these two residents from the facility's tracking matrix suggested potential problems with the admission screening process and ongoing monitoring of residents requiring special precautions. The four-month delay in implementing precautions for the quadriplegic resident indicated that routine auditing systems failed to identify and correct the oversight despite multiple opportunities during physician visits, nursing assessments, and care plan reviews.
The facility's reliance on a single infection preventionist to implement all precaution signage created a vulnerable system lacking adequate backup procedures. While the infection preventionist stated that the Director of Nursing or unit managers should handle signage for weekend admissions or when she was unavailable, the documented failures suggested this backup system didn't function effectively in practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bradenton Health Care from 2024-07-12 including all violations, facility responses, and corrective action plans.
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