Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) for a resident with a urinary catheter who required total assistance with activities of daily living. The facility's policy required staff to don gloves and gowns and perform hand hygiene when providing care to residents on EBP, especially during activities such as transferring and toileting. During observation, a certified nursing assistant (CNA) assisted the resident to the commode without performing hand hygiene or donning gloves and a gown. The CNA also placed the resident's catheter bag on the floor before hanging it on the commode. Another staff member entered to assist, donned gloves but not a gown, and after assisting, removed gloves and performed hand hygiene, while the first CNA left the room without performing hand hygiene. Interviews with both staff members confirmed their awareness of the EBP requirements and acknowledged their failure to follow proper infection control procedures, including the use of personal protective equipment and hand hygiene. The director of nursing services also confirmed that all residents on EBP require staff to adhere to infection control practices and that catheter bags should not be placed on the floor. These lapses in protocol placed residents at risk for transmission of infection.