Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with multiple diagnoses, including metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure. The resident was on EBP due to the presence of an indwelling urinary catheter, as documented in the care plan and indicated by signage at the resident's doorway. The CNA entered the resident's room wearing gloves but did not don a gown while performing high-contact care activities, such as emptying the catheter drainage bag. The CNA also failed to change gloves after providing catheter care and proceeded to touch multiple surfaces, including the shared bathroom door, bed remote, and the resident's clean clothing, without changing gloves. The deficiency was further substantiated by staff interviews and facility policy review. Another CNA reminded the staff member to wear a gown, at which point the gown was applied only for transferring the resident out of bed. The Director of Nursing confirmed that all staff are required to wear both gown and gloves during high-contact care for residents on EBP and to change gloves after catheter care to prevent cross-contamination. The facility's policy, revised on 6/30/25, mandates the use of gown and gloves for high-contact activities involving residents with indwelling medical devices, regardless of colonization status, to reduce the transmission of multi-drug-resistant organisms.