Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Facility staff failed to implement proper infection prevention and control measures, specifically Enhanced Barrier Precautions (EBP), for a resident with an indwelling urinary catheter. Multiple observations revealed that staff did not consistently don gloves or gowns when performing high-contact care activities, such as emptying the urinary catheter bag or handling the catheter and tubing. On several occasions, staff entered the resident's room and assisted with care or handled the catheter bag without wearing gloves or gowns, despite the presence of EBP indicators and available personal protective equipment (PPE). The urinary catheter bag and tubing were also observed uncovered and placed on the floor, and staff picked them up without gloves. The facility's policies required the use of EBP, including targeted gown and glove use during high-contact care activities for residents with devices such as urinary catheters. Staff interviews confirmed awareness of EBP indicators, but also acknowledged lapses in following protocol, such as forgetting to wear a gown or failing to use gloves when handling the catheter bag. The facility's own policies emphasized the importance of these precautions to prevent the transmission of multidrug-resistant organisms and reduce infections, but these were not consistently followed during the survey period.