Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines regarding Enhanced Barrier Precautions (EBP) during the provision of indwelling urinary catheter care for two residents with urinary retention and indwelling catheters. Facility policy required the use of EBP, including wearing gowns, gloves, and face shields during device care for residents with indwelling catheters. However, during multiple observations, staff members performed catheter care using only gloves and did not wear gowns or face shields as required. Interviews with certified nurse aides revealed inconsistent understanding and application of EBP protocols, with some staff believing gowns were only necessary for residents with wounds, and others acknowledging they should have worn additional PPE but did not obtain it prior to providing care. The residents involved had documented orders and care plans specifying the need for catheter care and EBP due to their indwelling urinary catheters. Despite receiving training on EBP, staff did not consistently implement the required precautions. The Director of Nursing confirmed that staff were expected to follow EBP protocols and to notify management if PPE was unavailable, but this expectation was not met during the observed care events.