Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident who was on enhanced barrier precautions (EBP) due to a wound on the sacrum. The resident, who was dependent on staff for all activities of daily living and had diagnoses including dementia, seizure disorder, and contractures, was identified as requiring EBP as per the care plan and signage outside the room. Despite this, staff members, including a trained medication assistant and a nursing assistant, entered the resident's room and provided direct care, such as medication administration and transferring the resident using a full body lift, without donning the required PPE. The staff had direct contact with the resident and her bedding during these activities. Interviews revealed that the staff were unaware that the resident was on EBP, even when shown signage and a poster indicating the precautions. There was also no PPE bin directly outside the resident's room, although one was available across the hallway. The facility's policy required the use of gown and gloves during high-contact care for residents with wounds or at increased risk of multidrug-resistant organism (MDRO) acquisition, but this protocol was not followed during the observed care activities.