Failure to Perform Hand Hygiene After Foley Catheter Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to perform hand hygiene after contact with a resident's Foley catheter while the resident was on Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including hypertension, type 2 diabetes mellitus, COPD, protein-calorie malnutrition, and dysphagia. During an observation, the LVN was seen wearing gloves while touching the resident's Foley catheter and bag, then removed the gloves, shook hands with the resident, and exited the room without performing hand hygiene. Interviews with the LVN, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that facility policy requires hand hygiene after glove removal and after contact with devices such as urinary catheters, especially for residents on EBP. The LVN acknowledged the oversight, and both the IP and DON stated that the expectation is for staff to wear appropriate PPE and perform hand hygiene as outlined in facility policies.