Failure to Implement Enhanced Barrier Precautions for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including urinary tract infection, obstructive and reflux uropathy, and generalized muscle weakness, required substantial assistance with activities of daily living and had a physician's order for regular catheter care. Despite these risk factors, there was no EBP sign or personal protective equipment (PPE) cart placed outside the resident's room, as observed during a facility visit. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the resident should have been placed on EBP due to the presence of a urinary catheter, which is considered a device requiring such precautions. Both the IP and DON acknowledged that the absence of an EBP sign and PPE cart was an oversight and that these measures are necessary to remind staff to perform hand hygiene and use appropriate PPE during high-contact care activities, such as dressing, bathing, transferring, and device care. A review of the facility's policy on Enhanced Barrier Precautions indicated that EBP should be implemented for residents with device care needs, including urinary catheters, and that appropriate signage and PPE should be made available outside the resident's room. The failure to follow these established protocols resulted in a deficiency, as the resident was not provided with the required infection control measures to help prevent the development and transmission of communicable diseases and infections.