Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use proper personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP) for the prevention of multi-drug resistant organism (MDRO) transmission. The resident had moderate cognitive impairment, an unhealed stage two pressure ulcer, and a skin tear, and their care plan required the use of gown and gloves during high-contact care activities. During an observed medication pass, three staff members repositioned the resident and assisted with drinking water, making contact with the resident and bedding multiple times without wearing PPE. Interviews with the involved nursing assistants and trained medication assistant confirmed awareness that the resident was on EBP, but they stated they only wore gowns for certain personal care activities, such as changing briefs or wound care. The infection prevention RN and DON both confirmed that PPE should have been worn during repositioning and adjusting bedding, as indicated by facility policy and signage. Facility policy, dated March 2025, specified following CDC guidelines for gown and glove use during high-contact care to reduce MDRO transmission.