Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a wound nurse failed to use the required personal protective equipment (PPE) while providing wound care to a resident who was under Enhanced Barrier Precautions (EBP). During the observed wound treatment, the nurse performed hand hygiene and donned gloves but did not wear a gown, despite an EBP sign being posted on the resident's door. The nurse acknowledged forgetting to put on the gown when questioned. The resident was in bed, covered with blankets, and was observed to be cold and crying at the time of care. The wound care involved opening the resident's brief, placing a new pad, and preparing a collagen dressing for application. The resident had significant medical conditions, including hemiplegia, dementia, and was at risk for pressure ulcers, requiring substantial assistance with daily activities and being dependent for toileting and lower body care. The facility's infection prevention nurse indicated that their policy allowed discretion regarding EBP, stating that if a wound could be covered and was not draining, EBP might not be necessary. However, current CDC guidance requires both gown and gloves for high-contact care activities, such as wound care, under EBP. The failure to follow these guidelines led to the cited deficiency.