Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow required infection prevention protocols for a resident on enhanced barrier precautions. The resident, who had a feeding tube, was identified as needing enhanced barrier precautions, which included the use of gloves and gowns during high-contact care activities such as changing incontinence briefs. On the observed date, two certified nursing assistants entered the resident's room to provide incontinence care. Although they wore gloves, they did not wear gowns as required by the posted signage and facility policy. During the care, both staff members also touched the resident's tube feeding equipment. Interviews with the staff and the infection control nurse confirmed that gloves and gowns should be worn when providing incontinence care to residents on enhanced barrier precautions, especially those with implanted medical devices like feeding tubes. The resident's care plan and the facility's policy both specified the need for appropriate PPE during high-contact care activities to reduce the risk of transmission of multidrug-resistant organisms. The failure to wear gowns during the care activity constituted a breach of the facility's infection control program.