Failure to Follow Enhanced Barrier Precautions and Infection Control During Resident Care
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions (EBP) and infection control protocols for residents requiring such measures. For one resident with a suprapubic catheter and a history of chronic urinary tract infections, staff did not don a gown as required during high-contact care activities, such as emptying the catheter. The staff member only wore gloves, placed the urine collection graduate directly on the carpeted floor without a barrier, and did not cleanse the catheter port with alcohol before or after emptying the catheter. The staff member also used gloved hands to open the bathroom door and handled the graduate and bathroom fixtures without changing gloves or using additional protective measures. These actions were inconsistent with the facility’s EBP policy and the indwelling catheter competency checklist, both of which require the use of a gown, gloves, and a disposable barrier during such procedures. Interviews with facility staff, including a CNA, LPN, RN, and the DON, revealed inconsistent understanding and application of EBP requirements. While some staff indicated that gowns, gloves, masks, and goggles should be used for catheter care, others stated that only gloves were necessary, depending on the resident’s illness or immune status. The DON confirmed that EBP, including gown and gloves, was required for residents with catheters or wounds, and that the observed practices did not meet facility expectations. In a separate incident, staff failed to maintain proper infection control during incontinence care for another resident with impaired skin integrity and open areas on the buttocks. Staff prepared washcloths for perineal care by placing them in a sink used for handwashing, which was also shared by the resident’s roommate. The DON, who also serves as the facility’s Infection Preventionist, confirmed that washcloths should not be left in a handwashing sink, as it is considered a dirty area. These lapses in infection control practices were directly observed during care and confirmed through staff interviews.