Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one resident who had an indwelling urinary catheter, as required by both facility policy and CDC guidance. The resident, who had severe cognitive impairment and urinary retention, was observed multiple times without appropriate EBP measures in place. Specifically, there was no signage or precaution cart with personal protective equipment (PPE) outside the resident's room, and the resident's care plan and physician's orders did not indicate the need for EBP. Staff were observed providing care to the resident while wearing gloves but not gowns, which is inconsistent with EBP requirements for residents with indwelling devices. Interviews with staff revealed a lack of awareness and understanding regarding the need for EBP for residents with catheters. The assigned CNA stated that only gloves were necessary, and did not recognize that the resident was on precautions. A nurse and the Director of Nursing both acknowledged that residents with catheters should be on EBP, and the DON admitted she was unaware that this resident was not on EBP. These actions and inactions led to the failure to implement required infection prevention and control measures for the resident.