Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices when providing care to a resident with an indwelling catheter who was on Enhanced Barrier Precautions (EBP). During an observed episode of catheter and peri care, two CNAs entered the resident's room, applied gloves, but did not perform hand hygiene prior to care or don gowns as required by EBP protocols. One CNA assisted the resident with standing using a gait belt, while the other performed catheter and peri care, including cleansing the catheter, penis, and buttocks, and then assisted with dressing. After care, one CNA removed gloves and performed hand hygiene, while the other removed gloves, gathered trash, exited the room, and only performed hand hygiene in the hallway outside the soiled utility room. Interviews with staff revealed a lack of understanding regarding the requirement to wear gowns during catheter and peri care under EBP, with some staff believing gowns were only necessary when emptying the catheter or not required during bowel movements. The facility's policies, as confirmed by the DON and LPN, required gowns and gloves for all catheter and peri care, as well as hand hygiene before and after resident contact and glove use. The observed practices did not align with these policies, resulting in a failure to implement proper infection prevention measures for a resident with an indwelling catheter.