Failure to Implement Enhanced Barrier Precautions and Sterile Technique During Catheter Care
Penalty
Summary
The facility failed to follow safe infection control practices in two separate instances involving residents with indwelling urinary catheters. In the first instance, a resident with a suprapubic catheter and neurogenic bladder was placed on Enhanced Barrier Precautions (EBP), as indicated by a red marker at the room entrance and documented in the care plan. Despite this, three Psychiatric Technician Apprentices provided personal hygiene care to the resident without wearing the required gowns and gloves. Both a Nursing Instructor and a Registered Nurse confirmed that EBP was in place for this resident and that gowns and gloves should have been used during personal care, as outlined in the facility's EBP policy for residents with indwelling urinary catheters. In the second instance, a resident with a history of neurogenic bladder and repeated urinary tract infections, who had a suprapubic catheter, did not receive sterile technique during catheter irrigation. A Registered Nurse prepared irrigation solutions in non-sterile medication cups on a non-sterile surface and used non-sterile gloves and a non-sterile syringe to perform the procedure. The nurse also failed to disinfect the catheter port with an alcohol pad before irrigation. The Infection Control Nurse and facility policy confirmed that irrigation of a suprapubic catheter should be performed as a sterile procedure, following CDC guidelines, and that aseptic technique and disinfection of the port are required steps. These observed failures to implement EBP and sterile technique during high-risk care activities were confirmed through interviews, record reviews, and direct observation. The facility's own policies and procedures, as well as staff statements, supported that the required infection control measures were not followed in these cases.