Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to utilize enhanced barrier precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. The resident, who had diagnoses including hypertension, coronary artery disease, depression, and severe cognitive impairment, required an indwelling catheter due to hydronephrosis with ureteropelvic junction obstruction. The care plan for this resident did not include directives for EBP, despite the presence of a catheter. Facility signage and policy required the use of gloves and gowns for high-contact activities involving indwelling devices, in accordance with CDC guidance. During observation, a CNA entered the resident's room to empty the urinary catheter bag, performed hand hygiene, and wore gloves, but failed to don a gown as required by EBP protocols. The CNA later acknowledged forgetting to use the gown. The Assistant Director of Nursing/Infection Preventionist confirmed that EBP should be used for residents with catheters and that the care plan should reflect this requirement. The facility's policy also directed the use of gowns and gloves for such care, but this was not followed in practice for the resident in question.