Failure to Use PPE During Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) protocols during the provision of catheter care for a resident with multiple medical conditions, including an indwelling catheter. Despite a sign on the resident's door indicating the need for gloves and a gown during high contact care activities, two Certified Nursing Assistants (CNAs) did not don the required personal protective equipment (PPE) while performing catheter care. Both CNAs confirmed in interviews that they were aware the resident was on EBP and acknowledged not wearing gloves or a gown during the procedure. The resident involved had a history of cerebrovascular disease, a right arm fracture, obstructive and reflux uropathy, dysphagia, cognitive communication deficit, difficulty walking, arteriosclerotic heart disease, age-related physical debility, and a lumbar vertebrae compression fracture. The resident was severely cognitively impaired, used a wheelchair, and had a physician's order for foley catheter care every shift, as well as an order for EBP due to the presence of the catheter. Facility policy and CDC guidelines require the use of gloves and gowns for high contact care activities for residents on EBP, particularly those with indwelling devices, but these protocols were not followed during the observed care.