Failure to Use PPE During Perineal and Catheter Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during perineal and incontinent care for a female resident with an indwelling Foley catheter. The resident, who was cognitively intact and dependent on staff for perineal hygiene, had a care plan and physician orders specifying the use of enhanced barrier precautions (EBP), including gloves and gowns, during high-contact care activities. Despite clear signage and the availability of PPE supplies in the resident's room, two restorative nursing assistants (RNAs) and a licensed vocational nurse (LVN) performed perineal and catheter care without donning the required gowns, although they did wash their hands and use gloves. Interviews with the involved staff and nursing leadership confirmed that the staff had been trained on EBP and were aware of the requirement to use PPE during such care. The staff acknowledged their failure to use PPE, attributing it to nervousness during the observed care. The facility's EBP guidance, as provided by the DON, reiterated the necessity of PPE for residents with indwelling devices during high-contact care, regardless of multidrug-resistant organism status.