Failure to Ensure Proper PPE Use and Linen Handling for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff consistently wore appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP) or transmission-based precautions. In one instance, a CNA entered a resident's room, which was marked with an EBP sign, and provided direct care involving wound dressings and offloading boots without wearing a gown or gloves, only a mask. The CNA was unaware of the resident's EBP status, believing the sign was left from a previous room assignment, despite the resident's care plan and physician orders indicating multiple wounds requiring EBP. Another incident involved a CNA providing peri-care and transferring a resident with multiple wounds while only wearing gloves and not a gown, despite an EBP sign posted outside the room. The CNA was unsure of the reason for the precautions, although documentation confirmed the resident was on EBP due to wounds. The care plan specified the need for gown and gloves during high-contact care activities, which was not followed during the observed care. A third case involved two CNAs changing the incontinence brief and bed linens of a resident with a stage 4 sacral pressure injury, both wearing only gloves and not gowns. One CNA carried soiled linens against her body and dropped a sheet in the hallway, and did not use a linen bag as required by facility policy. The Assistant Director of Nursing confirmed that gowns and gloves are required for EBP and that soiled linens should be bagged before removal from the room. Documentation for all three residents indicated the need for EBP due to wounds, and the facility's policy required proper handling of soiled linens to prevent contamination.