Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use required personal protective equipment (PPE), specifically gowns and gloves, during high-contact care activities for a resident who was under enhanced barrier precautions (EBP) due to a multidrug-resistant organism (MDRO). The resident, a male with severe cognitive impairment and multiple diagnoses including candidal sepsis and diverticulitis with perforation, had physician orders and a care plan in place requiring EBP for high-contact activities such as dressing, bathing, transferring, and changing linens. On one occasion, a CNA was observed making the resident's bed without wearing any PPE, despite the care plan and facility policy specifying that gown and gloves should be used during such activities. Further review revealed inconsistencies in the availability and signage of PPE for the resident. Initially, no signage or PPE was present in or outside the resident's room, but later signage and a PPE supply bin were observed. The CNA involved stated that PPE was only necessary for residents in isolation and believed the resident was no longer under such precautions, indicating a lack of understanding of EBP requirements. The Assistant Director of Nursing/Infection Preventionist confirmed that the resident was still under EBP and that staff were expected to use PPE during high-contact care, including linen changes.