Failure to Use Required PPE During Wound Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a registered nurse provided wound care to a resident who was under enhanced barrier precautions without wearing a gown, as required by facility policy and the signage posted on the resident's door. The nurse performed hand hygiene and changed gloves appropriately during the procedure, but failed to don a gown at any point, despite the clear instructions for personal protective equipment (PPE) use for residents on enhanced barrier precautions. The nurse acknowledged after the procedure that a gown was not worn and confirmed the presence of the PPE signage. The resident involved had diagnoses including chronic obstructive pulmonary disease, hypertension, and heart failure, and was care planned for impaired skin integrity with wounds on the left breast and neck. The resident required extensive assistance with all activities of daily living and had moderate cognitive impairment. This lapse in infection control practice affected one resident directly but had the potential to impact all 29 residents who were ordered enhanced barrier precautions at the facility.