Federal inspectors documented multiple violations of Enhanced Barrier Precautions at Alamo Nursing Home in September, finding staff repeatedly failed to follow infection control protocols designed to prevent drug-resistant bacteria transmission.
Resident 108 required the enhanced precautions due to a urinary catheter and pressure wounds, according to physician orders dated August 26. The protocols mandated gowns and gloves during dressing changes, bathing, toileting, transfers, linen changes, and wound care.
But staff ignored the requirements during a September 17 observation by inspectors.
The resident reported her pants were "soaking wet" when a certified nursing assistant and licensed practical nurse entered her room at 8:45 AM. Neither worker wore the required protective equipment.
Inspectors found the catheter tubing twisted on the resident's leg and filled with urine. The LPN explained that urine was flowing back into the resident's bladder because the catheter placement was incorrect, causing overflow onto the bed.
The LPN adjusted the catheter and removed a securement device from the resident's leg. The CNA performed incontinence care, rolling up a wet pad from underneath the resident and pulling it out.
Inspectors observed the resident's buttocks showed "a large non-blanchable area in the middle and a large open wound on the right buttocks."
The nursing assistant then grabbed a tube of barrier cream from the nightstand and applied it directly over the wounds. Neither staff member wore gowns during the entire care episode.
The resident's wound conditions had been deteriorating rapidly. A September 16 wound assessment documented a Stage 3 pressure ulcer on the right buttock measuring 6.0 centimeters by 2.9 by 0.1, with blood-tinged drainage. The area was described as "fragile and declined."
Nursing notes indicated "the wound significantly increased in size between assessments."
Unit Manager X confirmed the wound had worsened when she assessed it on September 16. During an inspector observation the next day, she reported the wound "looked much worse than the day before."
The unit manager also violated the enhanced barrier precautions, failing to wear a gown while helping reposition the resident in bed during the inspection.
When questioned, Unit Manager X acknowledged that Resident 108 required Enhanced Barrier Precautions due to her wounds and catheter. However, she admitted the requirements were not posted at the resident's door, a basic infection control measure.
The facility's own care documentation, called a Kardex, clearly specified that gowns and gloves were required for "dressing, bathing, showering, changing of briefs or toileting, personal hygiene, transferring, changing linens, device and/or wound care."
Enhanced Barrier Precautions represent a critical infection control strategy where staff wear gloves and gowns during high-contact resident care to reduce transmission of drug-resistant bacteria. The protocols are particularly important for residents with open wounds and medical devices like catheters, which create pathways for dangerous infections.
The resident had been admitted to Alamo Nursing Home with a pressure ulcer of the tailbone among her diagnoses. Pressure wounds develop when sustained pressure cuts off blood flow to skin and underlying tissue, often affecting bedridden or wheelchair-bound residents.
Federal inspectors determined the facility's failure to implement the physician-ordered precautions created "potential for residents to acquire avoidable drug-resistant infections."
The violation affected what inspectors classified as "few" residents, though the inspection focused specifically on infection control practices for three residents total.
The September 22 complaint inspection resulted from concerns about infection prevention and control practices at the facility. Inspectors found the facility failed to provide and implement an adequate infection prevention program.
Resident 108's case illustrates how basic infection control failures can compound existing medical problems. Her catheter complications, combined with staff violations of protective protocols, created multiple opportunities for bacteria transmission during a period when her wounds were actively deteriorating.
The twisted catheter tubing that inspectors observed represents a serious medical issue beyond the infection control violations. When urine flows backward into the bladder, it can cause urinary tract infections and other complications, particularly dangerous for residents with compromised immune systems or existing wounds.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alamo Nursing Home Inc from 2025-09-22 including all violations, facility responses, and corrective action plans.