Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to ensure proper implementation of its Infection Control Program, specifically in the use of Personal Protective Equipment (PPE) during wound care for a resident on Enhanced Barrier Precautions. The resident, who had a history of a cerebral vascular accident with aphasia, falls, and weakness, was moderately impaired cognitively and had an unstageable pressure ulcer. The physician's orders required daily wound care, which included cleaning and dressing the wound. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care on the resident without wearing a gown, despite the Enhanced Barrier Precaution sign at the room entrance instructing staff to wear both gloves and a gown for high-contact activities. Interviews with staff, including the LPN, a Registered Nurse Manager, and the Director of Nursing, confirmed that the resident was on Enhanced Barrier Precautions due to a COVID-19 outbreak on the unit. The staff acknowledged that gowns should have been worn during wound care to prevent the spread of infection. The facility's policy required signage and appropriate PPE for rooms with transmission-based precautions, but this was not adhered to during the observed incident, leading to a deficiency in infection control practices.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 Directed Plan of Correction 1. The facility hired the services of a consultant to in-service infection Preventionist and staff educator on 03/10/2025. The consultant developed and implemented an acceptable plan of correction. 2. The facility QA Committee met on 03/06/2025 to examine the deficiencies cited. A. The QA committee's assessment of the causative factors contributing to the deficiencies was that agency staff was not adequately trained on using PPE for Enhanced Barrier Precaution. B. Facility infection Preventionists educated Licensed practical nurses on proper PPE use regarding resident #21. The infection prevention will round the facility daily on each shift to ensure staff and contracted services adhere to appropriate PPE use. C. Two Weekly PPE audits will be conducted on all units. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Directed Inservice All nursing staff will be in service from 3/10/2025 through 04/14/2025 on proper PPE use for all residents during wound care. B. The infection preventionist or designee will conduct a walkthrough of the building. Observation of nursing staff on the proper use of PPE. C. Ad hoc education will be provided to persons not correctly implementing infection prevention and control procedures. Responsible Party: Director of Nursing