Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an abdominal feeding tube and moderate cognitive impairment. During high-contact care activities, including transferring the resident from a wheelchair to bed, assisting with positioning, and checking the resident's incontinence brief, two Certified Nursing Assistants (CNAs) wore gloves but did not wear gowns as required by the facility's EBP policy. Signage on the resident's door clearly indicated that both gloves and gowns were required for high-contact care activities such as transferring and changing briefs. The CNAs involved acknowledged that they had received training on EBP but one CNA admitted to forgetting the resident was on these precautions and sometimes not noticing the posted signage. The Director of Nursing/Infection Preventionist confirmed that the resident was on EBP and that staff were required to wear both gowns and gloves during high-contact care. Review of the facility's policy and physician orders confirmed the requirement for EBP, including the use of gowns and gloves for specified care activities.