Failure to Implement Enhanced Barrier Precautions and Maintain Catheter Hygiene
Penalty
Summary
Facility staff failed to consistently implement Enhanced Barrier Precautions (EBP) and maintain proper infection control practices for a resident with a urostomy and neurogenic bladder. Observations revealed that the resident's urostomy tubing was allowed to drag on the floor while she moved through the facility in her wheelchair. Staff interviews confirmed that catheter tubing is expected to be kept off the floor, but this was not adhered to during the observed incident. The resident was dependent on staff for transfers and toileting hygiene, and her care plan included the use of EBP to prevent infection. Additionally, during a high-contact care activity involving emptying the resident's urinary drainage bag, a Certified Nurse Aide (CNA) failed to wear a gown as required by EBP protocols, although gloves were used. The facility's policy mandates the use of gowns and gloves for high-contact activities involving residents with indwelling medical devices such as urinary catheters. Staff interviews and policy reviews confirmed the expectation for EBP use and proper handling of catheter tubing, but these standards were not consistently followed for this resident.