Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically by not implementing Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. According to the facility's policy, residents with indwelling medical devices, such as urinary catheters, should be placed on EBP, which includes the use of gown and gloves during high-contact care activities. Observations revealed that there was no EBP signage on the resident's door, and the resident was not placed on EBP despite having a urinary catheter. Interviews with staff, including the Director of Nursing and the Infection Preventionist, confirmed that the resident should have been on EBP and that the required signage and precautions were not in place. Additionally, during an observation of catheter care, an LPN performed the procedure wearing only gloves and not a gown, contrary to the facility's policy for EBP. The LPN stated that only gloves were necessary for catheter care and confirmed that she did not use a gown. The Infection Preventionist also confirmed that staff should wear both gown and gloves when providing direct care to residents on EBP and acknowledged that the resident with the urinary catheter was not on the appropriate precautions. The resident in question had a history of benign prostatic hyperplasia with urinary retention and a urinary tract infection, and had an indwelling catheter in place at the time of the deficiency.