Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the care of a resident with an indwelling urinary catheter. During an observed transfer of the resident to the toilet, CNA B only donned gloves and did not wear a gown, despite facility policy and infection control guidelines requiring both gown and gloves for high-contact care activities involving residents with indwelling medical devices. The CNA acknowledged that she was supposed to use the PPE provided in the room, which included gowns and gloves, but did not put on the gown. The ADON/IP and DON both confirmed that the facility's policy required staff to wear a gown and gloves during transfers for residents with urinary catheters. The resident involved was an older female with a history of urinary retention, lumbar fracture, osteoarthritis, hypertension, and chronic pain. She had an indwelling Foley catheter in place, with physician orders for catheter care and output monitoring every shift. The resident was cognitively intact and required maximum assistance for toileting. The deficiency was identified through observations, interviews, and record reviews, which confirmed that the required infection control precautions were not followed during direct care activities involving the resident's urinary catheter.