Failure to Use Required PPE During Urinary Catheter Care on Enhanced Barrier Precautions
Penalty
Summary
Nurse Aide (NA) #4 and NA #5 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during urinary catheter care for a resident who had an indwelling urinary catheter and was on EBP. Both staff members performed hand hygiene and donned gloves but did not wear the required gowns, despite clear signage on the resident's door indicating the need for gloves and gowns during high-contact care activities such as urinary catheter care. The necessary PPE, including gowns and gloves, was readily available at the entrance to the resident's room. Interviews with NA #4 and NA #5 revealed that both were aware of the EBP requirements and had received education on the use of PPE for such procedures. NA #5 stated she forgot to use the gown, and NA #4 indicated she was nervous and also forgot to don the gown. The Infection Preventionist and the Administrator confirmed that staff were responsible for checking signage and using appropriate PPE as indicated, and acknowledged that the required procedures were not followed during the observed care.