Failure to Use PPE During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention protocols when a treatment nurse and a certified nurse assistant did not wear the required personal protective equipment (PPE) during a suprapubic catheter change for a resident on Enhanced Barrier Precautions (EBP). Observation revealed that neither staff member donned complete PPE, despite signage indicating EBP outside the resident's room and a physician's order specifying the need for enhanced precautions due to the presence of a suprapubic catheter. The facility's policies and procedures require staff to perform hand hygiene and wear gowns and gloves for high-contact care activities, including catheter care, but these protocols were not followed during the observed procedure. The resident involved had multiple diagnoses, including hypertension, type 2 diabetes mellitus, Alzheimer's disease, and obstructive uropathy, and was assessed as having severe cognitive impairment and requiring moderate to maximum assistance with activities of daily living. Interviews with the treatment nurse and the infection preventionist confirmed that the facility's EBP protocol was not observed during the catheter change, and both acknowledged the expectation for staff to use proper PPE to prevent the spread of multidrug-resistant organisms. Review of facility policies further confirmed the requirement for PPE use during such procedures.