Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to follow appropriate infection prevention practices for a resident with an indwelling catheter who was on Enhanced Barrier Precautions (EBP). The resident, who had moderate cognitive impairment and required EBP due to the presence of an indwelling catheter, had care plans and physician orders specifying catheter care and the use of EBP supplies. During an observed catheter care procedure, a Certified Nursing Assistant/Certified Medication Assistant performed hand hygiene and wore gloves but did not don a gown as required by the facility's EBP policy. The staff member completed the catheter care without the gown, despite the policy stating that both gown and gloves must be worn during high-contact resident care activities for residents with indwelling medical devices. The Director of Nursing confirmed that the facility's expectation was for staff to wear a gown during any catheter care or contact with a catheter for residents on EBP. The facility's policy, implemented prior to the incident, clearly outlined the need for both gown and gloves during such care to prevent the transfer of multidrug-resistant organisms (MDROs). The failure to adhere to these established infection prevention protocols was observed and acknowledged by facility leadership.