Failure to Use Required PPE During Dressing Change Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a registered nurse failed to use appropriate personal protective equipment (PPE) during a dressing change for a resident with multiple medical conditions, including a malignant neoplasm of the esophagus, dysphagia, tracheostomy status, and a jejunostomy feeding tube. The resident had an order for the J-tube site to be cleaned and dressed three times daily, and a recent tracheostomy removal required daily bandage changes. During observation, the nurse donned gloves but did not wear a gown while changing the dressing, despite the presence of green drainage on the dressing and the resident's clothing. The resident's room had an Enhanced Barrier Precaution (EBP) sign posted, and the facility's EBP policy required both gown and glove use during high-contact care activities, such as device and wound care, for residents at risk of multi drug-resistant organism (MDRO) acquisition. The nurse acknowledged not wearing a gown during the procedure, which was inconsistent with facility policy and the posted precautions. This event was identified during a survey and affected one resident out of a facility census of 62.