Failure to Follow Enhanced Barrier Precautions During Indwelling Catheter Care
Penalty
Summary
A deficiency occurred when a nursing assistant failed to follow proper personal protective equipment (PPE) protocols while providing care to a resident on enhanced barrier precautions (EBP) due to an indwelling urinary catheter and a history of urinary tract infections and wounds. The resident, who had multiple medical conditions including diabetes, cerebral palsy, neurogenic bladder, paraplegia, and was dependent on staff for all personal care, required staff to don both gown and gloves during high-contact care activities as indicated by facility policy and signage posted outside the room. During the observed incident, the nursing assistant entered the resident's room wearing only gloves and a mask, but did not wear a protective gown as required. While emptying the urinary catheter bag, the assistant struggled with the catheter spout, resulting in urine splashing onto the floor and paper towels. The assistant handled the catheter tubing and collection container without consistently changing gloves or using proper hand hygiene between steps, and at times used bare hands to handle potentially contaminated items. The end of the catheter tubing was not wiped with an alcohol swab prior to emptying, contrary to facility policy, and the assistant acknowledged a lack of understanding regarding the specific PPE requirements for EBP. Interviews with other staff confirmed that the expectation was to use both gown and gloves when providing care to residents with indwelling catheters under EBP. Facility policies clearly outlined the need for enhanced barrier precautions for residents with indwelling medical devices, and signage was present to direct staff. The failure to adhere to these protocols was directly observed and acknowledged by the staff involved.