Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter, as required by facility policy. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder and urinary retention, was admitted with an indwelling urinary catheter. The care plan and physician's orders documented the presence of the catheter and the need for catheter care, but there were no specific orders for EBP. Observations revealed that there was no EBP signage or personal protective equipment (PPE) available at the resident's room, and staff did not use appropriate PPE during high-contact care activities, such as toileting and catheter care. During multiple observations, staff, including a CNA, assisted the resident with personal care and catheter management without donning the required gown and protective eyewear. The resident confirmed that staff did not wear gowns or protective eyewear during routine care or when emptying the catheter bag. Interviews with facility staff, including the RN Supervisor and Infection Preventionist, confirmed that the resident should have been on EBP due to the indwelling catheter, but the necessary precautions were not implemented.