Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
Staff failed to follow proper infection control practices during suprapubic catheter care for a resident. Specifically, a staff member entered the resident's room without performing hand hygiene, touched items in the room, and then exited to perform hand hygiene only after contact had already occurred. The same staff member performed suprapubic catheter care without wearing a gown, despite the presence of an Enhanced Barrier Precautions (EBP) sign on the resident's door, which indicated the need for gown and glove use during high-contact care activities such as catheter care. Another staff member was unaware of the reason for the EBP sign until reviewing the resident's care plan, which confirmed it was related to the suprapubic catheter. Facility policy required the use of gowns and gloves for such care to reduce transmission of multidrug-resistant organisms.