Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to implement appropriate infection control practices for residents with indwelling urinary catheters, specifically by not following Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. For one resident with significant medical conditions including metabolic encephalopathy, carcinoma in situ of the vulva, breast cancer, and Alzheimer's disease, staff did not don gowns while providing indwelling catheter care, despite the resident being dependent on staff for all activities of daily living. Observations showed that staff entered the resident's room wearing only masks and gloves, and did not use gowns as required by EBP during catheter care. Interviews revealed that staff believed EBP was not necessary unless a resident had a known multidrug-resistant organism (MDRO), and the Infection Prevention Nurse confirmed that EBP had been discontinued based on a misunderstanding of guidance, which was later acknowledged as incorrect. Another resident with Alzheimer's disease, dementia, and neuromuscular bladder dysfunction, also dependent on staff for personal care and with an indwelling catheter, did not have EBP signage or PPE available in the room. During peri-care, a CNA did not wear a gown, used a double-gloving technique not in line with facility policy, and failed to perform hand hygiene at appropriate times during the care process. The CNA was unaware of EBP requirements and stated that isolation precautions were not in place for the resident. The Infection Preventionist and Director of Nursing later confirmed that EBP should have been implemented for residents with indwelling devices, regardless of MDRO status, and that hand hygiene and proper glove use were expected but not followed. Review of facility policies confirmed that EBP should be used for residents with indwelling devices during high-contact care activities, and that hand hygiene is required before and after resident care and glove changes. The failure to implement EBP and proper hand hygiene as outlined in facility policy and CDC guidance led to deficient infection control practices for residents with indwelling catheters.