Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control program, specifically its enhanced barrier precautions policy, during catheter care for one resident. During an observation of catheter care, a CNA performed the care without wearing a gown, while a Unit Manager was present in the room. The resident involved had diagnoses including benign neoplasm of the bladder, neuromuscular dysfunction of the bladder, and a stroke affecting the left non-dominant side. The resident’s clinical record contained a physician’s order, dated 12/17/25, for enhanced barrier precautions every shift for the indwelling catheter. Interviews confirmed that facility leadership expected staff to wear a gown during catheter care. The Unit Manager stated that a gown should be worn when performing catheter care, and the DON also indicated that staff should use a gown when performing catheter care. The facility’s written policy on Enhanced Barrier Precautions, reviewed December 2022, required the use of gowns and gloves during high-contact resident care activities, including device care such as urinary catheters, to prevent the spread of multidrug-resistant organisms. Despite this policy and the physician’s order, the CNA did not wear a gown while providing catheter care to the resident.
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