Failure to Adhere to PPE Protocols for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) as per the facility policy and acceptable standards of infection control practice. This deficiency was observed during rounds on two units, involving two unsampled residents. In the first instance, a staff member approached a resident lying in bed, donned gloves, and checked the resident's condition without wearing a gown, despite a sign indicating that both gloves and a gown were required for high-contact resident care activities. The staff member acknowledged the oversight when questioned by the surveyor. In the second instance, another staff member was observed performing care on a different resident without wearing a protective gown, although a sign indicated that a gown was required. The staff member later explained that she had stepped out of the room to retrieve an item and did not wear a gown upon returning to complete the care. The surveyor noted that there was no evidence of a discarded gown in the room's garbage can, suggesting non-compliance with the facility's policy. Both residents involved had diagnoses that necessitated the use of Enhanced Barrier Precautions, which include donning gowns and gloves during high-contact activities to prevent the transmission of multi-drug resistant organisms. The facility's policy clearly outlines the procedures for managing such infections, yet the staff failed to adhere to these guidelines, leading to the observed deficiencies.
Plan Of Correction
Element 1 Upon discovering the breach in [R], the employees involved were immediately removed from direct care duties and counseled on the proper use of personal protective equipment (PPE) required for residents on NJ Ex Order 26.4(b)(1). On 1/3/25, all staff were retrained by the Assistant Director of Nursing on the facility's protocols regarding the appropriate use of PPE, including gloves and gowns when entering rooms of residents on enhanced barrier precautions. Element 2 All residents on Enhanced Barrier Precautions have the potential to be affected. Element 3 All staff underwent immediate re-education on the facility's enhanced barrier precaution protocols, emphasizing the importance of wearing gowns and gloves when caring for residents on enhanced barrier precautions. Staff were also re-educated on how to identify which residents need these precautions; all re-education was conducted by the Assistant Director of Nursing. Element 4 Enhanced Barrier Precaution spot check audits are being conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance with PPE protocols for residents on enhanced barrier precautions. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.