Failure to Follow Enhanced Barrier Precautions During Catheter and Wound Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during urinary catheter care and wound care for two residents. In the first instance, a resident with a neurogenic bladder and an indwelling urinary catheter required enhanced barrier precautions (EBP) due to the presence of a multidrug-resistant organism (MDRO) and pressure wounds. The care plan specifically directed staff to wear a gown and gloves during high-contact care activities, including catheter care. However, during an observed catheter care procedure, a certified nursing aide did not wear a gown as required, despite being aware of the EBP protocol. In the second case, a resident with severe cognitive impairment, a history of progressive neurological conditions, and a pressure ulcer was also under EBP for a chronic wound. The care plan instructed staff to wear a gown and gloves during high-contact care activities, including wound care. During an observed wound care procedure, an LPN performed the treatment without wearing a gown, even though the care plan still listed EBP as an active intervention. The LPN believed EBP was no longer necessary due to the wound's condition, but the care plan had not yet been updated to reflect this change. Both incidents were confirmed through staff interviews and direct observation. The Director of Nursing acknowledged that staff were expected to follow EBP protocols as outlined in the care plans and facility policy, which required gown and glove use for residents with indwelling devices or chronic wounds. The failure to adhere to these protocols resulted in the identified deficiencies.