Failure to Use Required PPE During High-Contact Care for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures by not ensuring staff used required personal protective equipment (PPE) during high-contact care for a resident with an indwelling suprapubic catheter. The resident had multiple urinary diagnoses, including bladder disorder, urethral stricture, benign prostatic hyperplasia, bladder neck obstruction, and overactive bladder, and required regular shaving of the head and body as part of activities of daily living. The care plan for the resident did not identify the need for Enhanced Barrier Precautions (EBPs) despite the presence of an indwelling catheter, and signage on the resident's door indicated the need for PPE during high-contact care activities. During observation, a nursing assistant entered the resident's room without performing hand hygiene or donning a gown, and only put on gloves after entering the room. The assistant proceeded to shave the resident's inner thigh, pubic area, buttocks, and arms, then exited the room carrying soiled supplies in gloved hands without performing hand hygiene. The assistant stated she had not been instructed to use a gown for this care activity and only used gloves. The director of nursing confirmed that EBPs, including gown and glove use, were required for residents with indwelling devices during high-contact care, and that these precautions should have been included in the care plan.