Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during a high-contact resident care activity. Specifically, a Certified Nursing Assistant (CNA), identified as Staff N, was observed performing peri-care on a resident without wearing the appropriate personal protective equipment (PPE), specifically a protective gown. This occurred despite the resident having a biliary drain in place, which necessitated enhanced barrier precautions. The CNA was only wearing gloves and was in close proximity to the resident's exposed peri-area when another staff member, Staff O, intervened by handing a protective gown through the door. The deficiency was further highlighted during interviews with the staff involved. Staff N was unable to provide a clear explanation for not donning the gown before starting the care procedure. Staff O acknowledged noticing the lack of PPE and acted by providing the gown. The Director of Nursing (DON), who also serves as the Infection Control Nurse, confirmed that the CNA should have worn the gown and mentioned that recent education on infection control procedures, including the use of PPE, had been provided to the nursing staff. The incident was documented with photographic evidence.
Plan Of Correction
Care was provided to resident #171 after a gown was provided to staff N by staff O inservice to nursing staff regarding Enhanced Barrier Precautions and donning gowns prior to care. DON or designee to do observational audits for Enhanced Barrier Precautions with gown donning prior to care 5 times weekly for 30 days and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.