Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed entering a resident's room and emptying the resident's indwelling urinary catheter bag while wearing gloves but not a gown, as required by the facility's infection control policies. The resident had a medical history that included infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, and obstructive and reflux uropathy. The CNA acknowledged during an interview that she should have worn a gown in addition to gloves but failed to do so because she was in a hurry, despite having received infection control training and having access to personal protective equipment. Further interviews with an LPN and the Director of Nursing confirmed that Enhanced Barrier Precautions (EBP), including the use of gloves and a gown, are required when providing catheter care or emptying a catheter, in accordance with facility policy. Review of the facility's policies on indwelling urinary catheter management and transmission-based precautions also specified the need for gloves and gowns during manipulation of the catheter or high-contact resident care activities. The failure to follow these infection control practices was identified through clinical record review, observation, and staff interviews.