Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring that staff used required Personal Protective Equipment (PPE) during high-contact care activities for a resident on Enhanced Barrier Precautions (EBP). Specifically, during an observed catheter care session, a Certified Nursing Assistant (CNA) provided care to a resident with an indwelling urinary catheter and a history of recurrent urinary tract infections caused by antibiotic-resistant bacteria, without donning a gown as required by both facility policy and CDC guidance. The CNA performed multiple high-contact activities, including catheter care, changing briefs, dressing, grooming, bed bath, and transferring the resident, all without wearing a gown, despite signage and policy indicating the necessity of gown and glove use for such care. Interviews with the CNA revealed awareness of the EBP requirements but an admission of forgetting to wear the gown. The resident confirmed that staff typically wear gowns during catheter care but sometimes forget. Facility leadership, including the Infection Preventionist and Director of Nursing, acknowledged the expectation for staff to wear gowns and gloves during high-contact care for residents on EBP and agreed with the findings when informed of the observed deficiency.