The violation occurred at Hallmark Healthcare of Pekin during a September inspection triggered by complaints. Federal inspectors found staff failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, despite physician orders requiring the protective measures.
On September 16, inspectors observed the resident in bed with a urinary drainage bag containing approximately 400 milliliters of clear yellow urine hanging from the bed frame. The resident's door displayed no sign indicating enhanced barrier precautions were required.
The next morning, hospice certified nursing assistant V4 performed the resident's personal hygiene care wearing only gloves and a mask. She then pushed the resident to the main dining room in his wheelchair.
When questioned about the facility's enhanced barrier precautions, V4 said she was unable to explain the protocols. She told inspectors she only wears gloves during personal care unless residents are on contact or droplet isolation. V4 confirmed she had worn only gloves and a mask while caring for the catheter patient.
Enhanced barrier precautions require additional protective equipment beyond standard precautions. The facility's own policy, revised in December 2024, mandates gowns and gloves during high-contact care activities for residents with indwelling medical devices like urinary catheters.
Assistant Director of Nursing V3, a licensed practical nurse, confirmed that signs should be posted outside residents' rooms indicating the type of isolation required. She verified that any resident with an indwelling urinary catheter should be on enhanced barrier precautions and that an isolation cart should be stationed outside the room.
V3 acknowledged the resident did not have the required sign on his door.
The facility's enhanced barrier precautions policy states the measures are used alongside standard precautions to expand protective equipment use. The protocol specifically targets prevention of multidrug-resistant organism transfer to staff hands and clothing during high-contact resident care.
Enhanced barrier precautions apply to residents with wounds or indwelling medical devices when secretions or excretions cannot be covered or contained, regardless of whether they are known to be infected with drug-resistant organisms.
The policy requires enhanced precautions during specific high-contact activities: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, and assisting with toileting. Device care activities also require the precautions, including central line maintenance, urinary catheter care, feeding tube management, tracheostomy care, and ventilator management.
Any wound care involving skin openings requiring dressings also mandates enhanced barrier precautions.
The inspection found the nursing assistant's failure to follow these protocols during personal hygiene care created potential for transferring drug-resistant organisms. Without proper gowns and gloves, staff hands and clothing can become contaminated during high-contact care activities.
The missing door signage compounded the violation by failing to alert other staff members about the required precautions. The absence of an isolation cart outside the room meant protective equipment was not readily available for staff providing care.
Federal inspectors classified the violation as having minimal harm or potential for actual harm to residents. The finding was part of a complaint investigation that examined infection control practices at the facility.
The violation demonstrates how gaps in infection control training and implementation can create risks for both residents and staff. When nursing assistants are unfamiliar with enhanced barrier precaution requirements, they may inadvertently contribute to the spread of dangerous drug-resistant infections throughout the facility.
The resident with the urinary catheter remained vulnerable to infection complications while other residents faced potential exposure through cross-contamination from inadequately protected staff members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hallmark Healthcare of Pekin from 2025-09-17 including all violations, facility responses, and corrective action plans.