Inadequate Use of PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for two residents under enhanced barrier precautions. Resident #10, who had chronic pressure ulcers and a history of osteomyelitis, was not provided with proper personal protective equipment (PPE) by Certified Nurse Aides during morning care. Despite the presence of precaution signage and available PPE, the aides did not wear gowns, which was a requirement for infection control. The aides admitted to not following the precautions due to nervousness and lack of attention to the signage. Resident #43, who had an ileostomy, was also not provided with proper PPE during care. Although signage indicated the need for a gown, gloves, and mask, the Licensed Practical Nurse only donned gloves and a mask while changing the ileostomy bag/flange. The nurse acknowledged forgetting to wear a gown, which was necessary for infection control. The facility's Infection Preventionist and Director of Nursing confirmed that enhanced barrier precautions were required for residents with invasive devices or open wounds to protect both the resident and staff from potential infections. The facility's policy on enhanced barrier precautions was not adequately implemented, as evidenced by the lack of PPE use during high-contact care activities for residents at risk of multi-drug resistant organism transmission. The care plans for both residents did not include specific interventions for enhanced barrier precautions, contributing to the oversight in infection control practices. Interviews with staff revealed a lack of adherence to the facility's infection prevention protocols, highlighting a deficiency in maintaining a safe environment for residents.
Plan Of Correction
Plan of Correction: Approved January 8, 2025 1. Resident #10, #43 and Resident #42 was reviewed by the Infection Preventionist. The careplan was reviewed and closet careplan was updated by Director of Nursing to reflect the Enhanced Barrier precautions needed to provide care. All staff assigned to Resident #10, Resident #43 and Resident #42 will be educated by the Infection Preventionist on proper Enhanced Barrier PPE needed to provide care. IDT team makes decisions based on current criteria for EBP for enhanced barrier precautions. It is the Unit manager/designee who ensures compliance of all residents on EBP. Any deficient practices will be corrected and brought to DON for review. 2. All residents with Enhanced Precaution Barriers are at risk for the deficient practice of staff not wearing proper PPE when providing care. 3. Director of Nursing reviewed the policy and procedure on Enhanced Barrier Precautions and no changes were made to the policy. 4. All staff were educated by the consultant on Enhanced Barrier Precautions. 5. An Audit of all residents on Enhanced Barrier Precaution was conducted by the Infection Preventionist to audit staff wearing of PPE. Any deficient practice will be corrected immediately and brought to QAPI for further review. 6. 5 residents on Enhanced Barrier Precautions will be audited weekly to ensure staff are wearing proper PPE when providing care. Any deficient practice will be corrected and brought to QAPI for further review. Person Responsible: Infection Preventionist