Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder, had a Minimum Data Set assessment indicating severe cognitive impairment and dependence on staff for ADLs. The resident’s care plan documented the presence of an indwelling catheter for skin breakdown and urinary retention, with an intervention specifying that staff were to maintain EBP due to the catheter, and physician orders also directed that the resident be on EBP. During observation, an EBP cart stocked with PPE was present outside the resident’s room, but when a CNA provided catheter care, the CNA did not don a gown as required. In a subsequent interview, the CNA confirmed awareness that the resident was supposed to be on EBP and acknowledged not wearing a gown while providing care. Review of the facility’s Isolation Precautions Process policy showed that EBP was to be used for residents with urinary catheters during their entire stay, which was not followed in this instance.
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