Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) during urinary catheter care for a resident with an indwelling catheter. Observations revealed that staff did not utilize required personal protective equipment (PPE) such as gowns and masks, as outlined in the facility's own EBP policy for residents with devices like urinary catheters. Specifically, a CNA was seen draining a urinary catheter without wearing an isolation gown or mask, using a towel and washcloth that had been on the floor, and carrying soiled items out of the resident's room while still wearing contaminated gloves. The CNA also demonstrated a lack of knowledge regarding EBP requirements. Similarly, an LPN performed catheter care without securing the catheter to the resident's leg and did not use an isolation gown or mask, also indicating unawareness of EBP protocols. Interviews with staff and the infection preventionist (IP) confirmed that the expectation was to use gloves and clean technique, but there was no consistent understanding or implementation of EBP, despite the facility's policy requiring gloves, gowns, and face shields for care involving artificial openings or tubing. The resident involved was cognitively intact and had an indwelling catheter, and reported that staff only wore gloves during care. The lack of visible EBP signage or equipment in the resident's room further demonstrated the facility's failure to follow its own infection control policies.