Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not adhering to Enhanced Barrier Precautions (EBPs) and proper hand hygiene during high-contact care activities for a resident with an indwelling suprapubic catheter. Specifically, a CNA performed catheter care for a female resident with spina bifida, paraplegia, and urinary retention, but did not wear a gown as required by facility policy for high-contact care involving indwelling medical devices. After completing the washing, rinsing, and drying of the catheter tubing and perineal area, the CNA did not change gloves or perform hand hygiene before applying a new incontinence brief and repositioning the resident in bed. The facility's policies clearly state that staff must wear gowns and gloves during high-contact care activities and must change gloves and perform hand hygiene after such procedures. The CNA acknowledged not following these procedures, and the DON confirmed that the correct protocol was not followed. The resident involved had a physician-ordered suprapubic catheter and required enhanced barrier precautions, as documented in her medical record and the facility's infection control policies.