Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. During an observation, a nurse aide entered the resident's room, washed her hands, and applied gloves but did not don a gown, despite gowns being available and required by the facility's EBP policy for catheter care. The nurse aide proceeded to provide catheter care, noted the presence of bloody urine, and completed the task without ever applying a gown. Upon interview, the nurse aide acknowledged forgetting to put on the gown and recognized, after reviewing the posted signage, that a gown was required for this type of care. A similar observation occurred with a nurse who assessed the same resident's indwelling urinary catheter. The nurse entered the room, washed her hands, and applied gloves but did not wear a gown while lifting the resident's gown and lowering the brief to assess the catheter insertion site. After completing the assessment, the nurse disposed of her gloves and washed her hands. In an interview, the nurse admitted to forgetting to apply a gown and confirmed that it was required for catheter care. Both the Staff Development Coordinator and the Director of Nursing confirmed that the staff should have worn gowns during these high-contact care activities, as outlined in the facility's EBP policy.