Failure to Use Proper PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper personal protective equipment (PPE) protocols for a resident on enhanced barrier precautions (EBPs) who had an indwelling catheter and required extensive assistance with care. The resident's care plan and signage on the door directed staff to wear gowns and gloves during high-contact care activities, including transfers. During an observed transfer, three staff members, including two nursing assistants and a registered nurse, only wore gloves and did not don gowns while assisting the resident with a transfer using a mechanical lift. After the transfer, they removed their gloves, sanitized their hands, and exited the room. Interviews with the involved staff confirmed that they were aware the resident was on EBPs and acknowledged that gowns should have been worn during the transfer, but they forgot to do so. The infection preventionist and the director of nursing both stated that staff are expected to wear gowns and gloves for high-contact care with residents on EBPs, including transfers. The facility's policy also required targeted use of gowns and gloves for residents with indwelling medical devices during high-contact care activities.