The violation occurred on November 12 at 7:50 AM at Chapters Living of Council Bluffs. Staff G, a CNA, properly completed hand hygiene and put on a gown and gloves before entering the resident's room. She followed appropriate infection control techniques while performing peri care and catheter care.
But then she removed her gloves and put on new ones without washing her hands before emptying the catheter bag.
The facility's Interim Director of Nursing watched the entire sequence unfold.
The resident, identified only as Resident #3, was under enhanced barrier precautions due to wounds and a urinary catheter. A CDC sign posted outside the room warned that staff must wear gloves and gown during high-contact care activities including dressing, bathing, transferring, hygiene tasks, device care and wound care.
Enhanced barrier precautions are infection control measures designed to prevent transmission of multi-drug-resistant organisms during high-contact resident care. The facility's own policy states these precautions apply to residents with CDC-targeted antibiotic-resistant bacteria, wounds, or indwelling medical devices when standard contact precautions don't apply.
The policy specifically requires targeted use of gowns and gloves, with face protection if there's risk of splash or spray during tasks.
After witnessing the hand hygiene failure, the Interim Director of Nursing explained the facility's expectations. Enhanced barrier precautions should be followed for residents with catheters, pressure ulcers, wounds and incisions, she said. Staff are expected to wear personal protective equipment when completing direct care tasks, using gowns and always wearing gloves.
When asked for clarification about glove use, she said staff should wear gloves whenever in the room, even when not completing tasks - giving the example of simply observing care.
Most critically, she confirmed that hand hygiene should be completed upon entry and exit from a resident's room, during incontinence care, and between glove changes.
The Administrator echoed these expectations. Staff must follow enhanced barrier precautions when required, and complete hand hygiene when changing gloves.
But the facility's own documentation revealed gaps in following these protocols. Resident #3's treatment administration record from November showed an order for enhanced barrier precautions related to urinary catheter and wounds, dating back to August 15. However, the documentation lacked entries for the overnight shift from 10 PM to 6 AM on November 3.
Another resident, Resident #2, was also under enhanced barrier precautions. Both residents had CDC signs posted outside their doors warning staff about required protective equipment.
The facility's hand hygiene policy acknowledges that handwashing is "the primary means to prevent the spread of healthcare-associated infections." The policy clearly states that hand hygiene is required before putting on non-sterile gloves and immediately after removing gloves.
This wasn't a case of staff being unaware of the rules. The facility's enhanced barrier precautions policy reveals that staff receive training before caring for residents on these protocols.
The violation represents a breakdown in basic infection control at a particularly vulnerable moment. Catheter care requires meticulous hygiene because urinary catheters create a direct pathway for bacteria to enter the body. Multi-drug-resistant organisms can cause life-threatening infections that are extremely difficult to treat.
Enhanced barrier precautions exist precisely because certain residents face heightened infection risks. Resident #3's combination of wounds and an indwelling catheter made proper hand hygiene between glove changes essential, not optional.
The timing made the failure more concerning. The violation occurred during the morning shift when the Interim Director of Nursing was present and available to provide guidance or correction in real time.
Instead, she watched a staff member skip a fundamental infection control step while caring for one of the facility's most vulnerable residents.
Federal inspectors documented the incident as part of a complaint investigation. The violation received a citation for minimal harm or potential for actual harm affecting few residents.
But for Resident #3, lying in bed while a staff member handled catheter equipment with contaminated gloves, the potential consequences were far from minimal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chapters Living of Council Bluffs from 2025-11-12 including all violations, facility responses, and corrective action plans.
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