Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters, as required by facility policy. During observations, one staff member was seen leaving a resident's room after assisting with a transfer using a mechanical lift, without donning any personal protective equipment (PPE). The resident had a catheter in place, and there was no PPE caddy available outside the room. The staff member admitted to not using PPE and stated she intended to retrieve supplies afterward. The resident confirmed that PPE was not always used during catheter care and noted that PPE supplies had previously been available but were removed, leading to more relaxed practices among staff. In another instance, a staff member entered a different resident's room, which had signage and a PPE caddy indicating the need for EBP, but did not don PPE before assisting the resident, who also had a catheter, with a transfer to the toilet. The staff member only wore gloves and stated she had just been informed that day about the requirement for PPE use with catheters. Interviews with other staff confirmed that EBP should be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks, such as transferring and toileting. Review of the facility's policy confirmed these requirements, but observations and interviews demonstrated inconsistent adherence.