Failure to Ensure Proper PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE), specifically gowns and gloves, during high-contact care activities for two residents who were under Enhanced Barrier Precautions (EBP) due to open wounds requiring dressings. Facility policy required staff to use PPE during high-contact activities such as dressing, transferring, providing hygiene, changing linens, toileting assistance, and wound care for residents with wounds. Observations revealed that staff did not consistently wear gloves during these activities, despite EBP signage and PPE availability outside the residents' rooms. For one resident with a pressure ulcer and a chronic non-pressure wound, nursing assistants completed toileting care and transferred the resident to bed without wearing gloves, touching the resident's clothing, blankets, and assisting with positioning. For another resident with a pressure ulcer, staff similarly completed toileting care and transferred the resident to bed without donning gloves, then touched linens, pillows, and the resident. The Director of Nursing confirmed that gloves should be worn during all high-contact care activities for residents under EBP.