F0880

D

Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Catheter Care

Lenoir, North Carolina Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to follow the facility’s Infection Control and Hand Hygiene policies during suprapubic catheter care for Resident #26. The facility’s Hand Hygiene policy required staff to perform hand hygiene before donning gloves and immediately after removing them, and the Enhanced Barrier Precautions (EBP) policy required use of gown and gloves for high-contact resident care activities, including providing hygiene to residents with indwelling urinary catheters. An EBP sign specifying the need for gown and gloves was posted on the resident’s door. During an observation of suprapubic catheter care, Nurse Aide #1 and Nurse #4 entered the resident’s room, removed gloves from the PPE tower, and applied gloves without donning gowns, despite the posted EBP sign.

While providing suprapubic catheter care, Nurse Aide #1 removed a dirty dressing from the suprapubic site, then removed her dirty gloves and applied clean gloves without performing hand hygiene. She then cleaned the suprapubic site and catheter tubing, removed her dirty gloves again, and applied clean gloves without using hand sanitizer between glove changes. Nurse #4 applied a dressing to the suprapubic site, then removed her gloves and washed her hands. In interviews, Nurse Aide #1 acknowledged the resident was on enhanced barrier precautions, stated she should have worn a gown, and admitted she did not wash her hands between glove changes. Nurse #4 stated she did not initially know the resident’s precaution status, did not pay attention to the EBP sign on the door, and believed she had not performed any care that warranted wearing a gown. The DON confirmed that both staff should have worn gowns for EBP and that hand hygiene should have been performed between glove changes.