Failure to Use Required PPE During High-Contact Care for Residents on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistant (CNA) 3 failed to wear an isolation gown while dressing a resident who was on enhanced barrier precautions (EBP) due to colonization with ESBL-producing E. coli. The resident had a history of chronic obstructive pulmonary disease, urinary tract infection, and atrial fibrillation, and required substantial assistance with activities of daily living. Despite signage indicating EBP and facility policy requiring gown and glove use for high-contact care activities such as dressing, CNA 3 was observed providing care without the required personal protective equipment. CNA 3 stated she was unaware of the resident's EBP status and the need to wear an isolation gown during care. A Licensed Vocational Nurse (LVN) also failed to don a gown while administering medications via a gastrostomy tube to another resident on EBP for a history of multidrug-resistant organism (MDRO) colonization and indwelling device use. The resident had severe cognitive impairment and required maximal assistance for most activities of daily living. The LVN confirmed not wearing a gown during the medication administration, despite a physician's order and facility policy specifying the need for gown and glove use during high-contact care activities, including device care for residents on EBP. Interviews with the Infection Preventionist and Director of Nursing confirmed that both staff members should have worn isolation gowns during these high-contact care activities, as required by facility policy and the residents' precaution status. The facility's policy, last reviewed in October 2024, clearly outlined the use of enhanced barrier precautions, including gown and glove use for residents with MDROs or indwelling devices during high-contact care activities such as dressing and device care.