Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper implementation of its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident with an indwelling urinary catheter and colostomy. The resident, admitted with an uninhibited neuropathic bladder and identified on the care plan as requiring EBP due to the presence of a colostomy and Foley catheter, had care instructions stating that gloves and a gown should be donned for high-contact activities such as linen changes, resident hygiene, and catheter care. Facility policy on EBP, as well as signage posted outside the resident’s room, directed staff to perform hand hygiene and wear both gown and gloves during high-contact care for residents with indwelling medical devices, including urinary catheters. On the observed date and time, an LVN entered the resident’s room to change the urinary catheter, performed hand hygiene, and donned gloves but did not put on a gown, despite gowns being readily available in a nearby plastic dresser and the posted EBP instructions outside the room. The LVN later acknowledged in an interview that she was supposed to use a gown when changing the catheter, stated she had been trained on EBP, and attributed the omission to being distracted. She also stated that not wearing a gown could lead to infection or cross contamination. The ADON and the Administrator both confirmed that the expectation was for nursing staff to use appropriate PPE, including EBP, when providing catheter care to this resident and that failure to do so could spread infections to and from the resident.
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