Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to implement infection prevention and control practices in accordance with the facility's Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling urinary catheter. During an observation, a Certified Nursing Assistant performed hygiene care for the resident, who was under EBP due to bacteriuria and the presence of an indwelling catheter. The staff member performed hand hygiene and donned gloves but did not wear a gown, which is a required component of PPE for EBP during high-contact care activities such as hygiene care. This omission was observed and reported to the Director of Nursing. Record review confirmed that the resident had a physician's order for EBP every shift and required substantial to maximal assistance for toileting hygiene care. The facility's policy, revised in April 2024, specifies that both gowns and gloves must be used for high-contact care activities involving residents at increased risk for multidrug-resistant organisms, including those with indwelling medical devices. The staff member acknowledged awareness of the EBP signage but did not follow the full PPE protocol during the observed care.