Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards of practice for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling urinary catheters. For one resident with Alzheimer's Disease and neuromuscular dysfunction of the bladder, a nurse did not perform hand hygiene before donning gloves and entering the resident's room, and only wore gloves—omitting the required gown—while performing a hands-on assessment of the urinary catheter. The nurse later acknowledged not following the EBP signage, and the unit manager confirmed that a gown was required for any hands-on catheter care. For another resident with incomplete paraplegia and neuromuscular dysfunction of the bladder, a unit manager performed hand hygiene, donned gloves only, and entered the resident's room to assess the indwelling urinary catheter. The unit manager did not wear a gown as required by the EBP signage for catheter care. Upon review, the unit manager acknowledged that a gown should have been worn during the procedure to prevent potential contamination. Both incidents were observed by surveyors and confirmed through interviews and review of facility policy and CDC guidelines. The facility's own policy and posted signage indicated that both gloves and gowns were required for high-contact care activities involving indwelling medical devices, such as urinary catheters, under EBP. The failure to follow these protocols was directly observed and acknowledged by the staff involved.