Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling suprapubic catheter. The resident was identified as cognitively intact and had diagnoses including neurogenic bladder and intestinal-genital tract fistulae. The care plan directed staff to wear a gown and gloves for high contact activities, such as emptying the catheter bag. During an observation of catheter care, a CNA donned a mask and gloves but did not wear an isolation gown while emptying the resident's catheter bag, despite the presence of PPE supplies and signage indicating EBP requirements in the resident's room. Interviews with staff and the Director of Nursing confirmed that EBP, including the use of gowns and gloves, should be followed for residents with indwelling catheters during high contact care activities. Review of the facility's policy also documented that gowns and gloves are required for such activities. The failure to don an isolation gown during catheter care was inconsistent with both the care plan and facility policy.