Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy during catheter care for a resident. During an observation, EBP signage was posted outside the resident's room, clearly indicating that staff must wear gloves and a gown for high-contact resident care activities, including device care such as urinary catheter care. However, an LPN performed catheter care for the resident by donning gloves but did not wear a gown prior to entering the room. The LPN completed the catheter care procedure, including cleaning the resident's penis and catheter tubing, and exited the room after removing gloves and performing hand hygiene. Immediately following the observation, the LPN acknowledged that she had not worn a gown during the procedure and stated that both gloves and gowns should be worn for such high-contact care, but she had forgotten to don the gown. The resident involved had multiple diagnoses, including hypertension, type two diabetes mellitus, unspecified dementia, and stage three chronic kidney disease. Physician orders for the resident included EBP for an indwelling catheter and regular catheter care. The facility's current policy, provided by the DON, specified the requirement for gown and glove use during high-contact activities, including catheter care.