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) due to a pressure ulcer. The resident, who had moderate cognitive impairment and diagnoses including COVID-19, depression, and metabolic encephalopathy, was care planned for gown and glove use during high-contact care. Observations showed that an LPN cut the resident's toenails without wearing a gown and leaned on the bed, despite being aware of the EBP requirements. Additionally, a physical therapy assistant assisted the resident with walking, transferring, and adjusting bed covers without wearing PPE, even though she acknowledged having received EBP training and knowing the resident was on EBP. Interviews with staff, including the clinical manager, infection prevention nurse, and director of nursing, confirmed that PPE should have been worn during these high-contact care activities. The facility's infection control manual specified gown and glove use for such activities, and all staff, including therapy, had been trained on EBP. Despite this, staff did not adhere to the required precautions during the observed care events.