Failure to Follow Enhanced Barrier Precautions and Catheter Care Protocols
Penalty
Summary
Staff failed to adhere to the facility's Enhanced Barrier Precautions (EBP) policy during the care of two residents who required these precautions due to the presence of indwelling medical devices. For one resident, a CNA assisted with a transfer and handled a catheter bag without wearing a gown, despite signage indicating the need for EBP. The CNA also placed the resident's feet on wheelchair pedals and hung the catheter bag from the wheelchair without proper PPE. For the second resident, a CNA transferred the resident to a wheelchair while wearing gloves but not a gown, handled linens and a Chux pad, and manipulated the catheter tubing and bag, which were observed in contact with the floor. The CNA only donned a gown later, prior to shower care, but again placed the catheter bag on the shower room floor before handing it to the resident. The Director of Nursing confirmed that staff are required to wear both gown and gloves during high-contact care activities for residents on EBP, including transfers, catheter care, and linen changes, and that catheter bags and tubing should not be in contact with the floor. The observed failures to follow EBP protocols and maintain catheter equipment off the floor were in direct violation of the facility's infection prevention and control policies.