Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP). During observations, two staff members assisted a resident with a history of MRSA infection and a current Stage 3 pressure ulcer on the left foot, without wearing gowns as required by EBP protocols. The resident was unaware of the purpose of the newly installed PPE holder on the door, and staff indicated unfamiliarity with the new PPE procedures, stating that the holders had just been installed and that they believed the gowns were only necessary for nurses during dressing changes. Further interviews revealed that staff were not consistently implementing EBP throughout the facility, despite recent re-education efforts. Review of the facility's infection control policy confirmed that EBP requires the use of gowns and gloves during high-contact care for residents with chronic wounds or a history of multidrug-resistant organism (MDRO) infection. The lack of adherence to these protocols was directly observed and acknowledged by staff.