Failure to Follow Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy regarding the use of personal protective equipment (PPE) when providing care to two residents with indwelling urinary catheters. In the first instance, a resident with multiple diagnoses including rheumatoid arthritis, malnutrition, heart failure, and neurogenic bladder was observed with her catheter bag uncovered and lying on the floor. A Care Plan Coordinator/LPN entered the room, picked up the catheter bag, placed it in a cover, and attached it to the bed without donning gloves or a gown, despite clear signage indicating enhanced barrier precautions and readily available PPE at the door. The resident's care plan specifically required staff to wear gown and gloves during activities of daily living due to the risk of infection associated with the indwelling catheter. In the second instance, two CNAs provided catheter care to another resident with multiple diagnoses, including multiple myeloma and obstructive uropathy, who also required enhanced barrier precautions due to an indwelling catheter. During the observed care, neither CNA donned gowns, even though enhanced precautions signage and PPE were available at the room entrance. The resident's care plan and physician orders both specified the need for gown and glove use during high-contact care activities. The facility's EBP policy, dated 10/6/22, mandates the use of gown and gloves for high-contact care activities for residents with indwelling medical devices, but this protocol was not followed in these observed cases.