F0880

D

Failure to Follow Enhanced Barrier Precautions During Catheter Care

Raleigh, North Carolina Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow Enhanced Barrier Precautions (EBP) during indwelling urinary catheter care. The facility’s EBP policy dated 4/2023 required the use of both gowns and gloves, in conjunction with Standard Precautions, for high-contact resident care activities, including device care for indwelling urinary catheters. The policy specified that EBP applied to residents with indwelling medical devices, such as indwelling urinary catheters, for the duration of the resident’s stay or until the device was discontinued. A sign posted on the resident’s door instructed that all healthcare personnel must wear gloves and a gown for urinary catheter care, and gowns and gloves were available at the room entrance.

On the survey date, a continuous observation of catheter care was conducted for Resident #4, who had an indwelling urinary catheter. Nurse Aide (NA) #1 performed hand hygiene and entered the room without wearing a gown, despite the posted EBP sign and available PPE. She explained the procedure, set up supplies, performed hand hygiene again, and donned gloves before assisting with positioning and opening the incontinence brief. As she prepared to clean the urinary catheter at the insertion site, the observation was stopped and she was asked to leave the room. In an interview immediately afterward, NA #1 acknowledged that the resident was on EBP, stated she had been educated on EBP, and correctly described that EBP required both gown and gloves for catheter care to prevent the spread of germs, but reported she had been nervous and forgot to wear a gown on this occasion. The DON and Administrator both confirmed that a gown and gloves should have been used for indwelling urinary catheter care under EBP.