Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols during the provision of catheter care to a resident with a suprapubic catheter who was under enhanced barrier precautions (EBP). Specifically, an LVN and a CNA were observed performing catheter care while wearing gloves but not gowns, despite an EBP sign being posted outside the resident's door and a physician's order for EBP related to the suprapubic catheter. Both staff members acknowledged during interviews that they were aware of the requirement to wear gowns in addition to gloves for residents on EBP, citing prior training, but stated they had forgotten to don the gowns during the care activity. The resident involved had a history of cerebral palsy and obstructive and reflux uropathy, and was assessed as having an indwelling suprapubic catheter. The facility's infection prevention and control policy, revised in April 2024, required the use of gown and gloves for high-contact care activities involving residents with indwelling medical devices, regardless of MDRO colonization status. The Director of Nursing Services confirmed that staff should have worn both gown and gloves during the care and that failure to do so was not in accordance with facility policy.