Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow infection prevention and control protocols while providing catheter care to a male resident with a history of urinary tract infection and benign prostatic hyperplasia. During the observed care, the CNA did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy, despite a posted sign indicating the need for EBP and a PPE station present in the room. The CNA wore gloves but omitted the gown, completed the catheter care, and performed hand hygiene afterward. The CNA later acknowledged missing the sign and not using the gown, attributing the oversight to being accustomed to PPE stations outside the room and recent management changes. Interviews with facility staff, including the CNA, DON, and ADON, confirmed that the expectation is for staff to wear both gloves and gowns during high-contact care activities such as catheter care, in accordance with the facility's EBP policy. The CNA reported prior training on EBP but was uncertain about the current infection control officer due to recent staff turnover. The DON and ADON reiterated the importance of proper PPE use to prevent cross-contamination, and facility documentation confirmed that device care requires both gloves and gowns under EBP.