Failure to Follow Enhanced Barrier Precautions and Catheter Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP) related to a suprapubic catheter. The resident was an adult male with hemiplegia and hemiparesis of the left non-dominant side, COPD, a history of UTI, and a bulbar urethral stricture, and had an indwelling catheter. His active orders and care plan required staff to use gown and gloves before room entry and during high-contact care activities, including catheter care, dressing, bathing, hygiene, and toileting, and to follow EBP protocols to prevent infection. During an observation, a CNA entered the resident’s room without wearing a gown or gloves, despite the resident being on EBP. The resident’s suprapubic catheter bag was on the floor near the bed. The CNA donned gloves without performing hand hygiene, picked the catheter bag up from the floor, emptied 580 ml of urine into a urinal, and then placed the catheter bag back on the floor. After discarding the used gloves, the CNA applied a new pair without hand hygiene and proceeded to provide incontinent care and dress the resident using the same pair of gloves. The CNA then picked the catheter bag from the floor and placed it on the resident’s bed to dress him, without sanitizing the bag, changing the bag, or changing the bed linens, and did not perform hand hygiene after completing care. In interviews, the CNA acknowledged she should have worn a gown, kept the catheter bag off the floor on a fixed structure below bladder level, and performed hand hygiene between glove changes and before handling the catheter bag. The charge nurse and DON stated their expectations that staff perform hand hygiene before, between, and after glove changes, keep catheter bags off the floor, and wear gowns and gloves for residents on EBP, consistent with facility policies on catheter care and the infection prevention and control program.
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