Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during high-contact care activities for residents requiring enhanced barrier precautions. In one instance, a resident with an indwelling catheter and a recent urinary tract infection was observed receiving catheter care from an LPN who wore gloves but did not don a gown, despite the facility's policy requiring both gown and gloves for such care. The resident's care plan indicated catheter care was to be performed every shift, and the resident was cognitively intact. The Director of Nursing later confirmed that enhanced barrier precautions, including gown and gloves, should have been used for this resident. In another case, a resident with a feeding tube and severe cognitive impairment was observed during feeding tube site care and medication administration. The LPN performed these tasks wearing gloves but did not use a gown, contrary to the facility's enhanced barrier precautions policy, which specifies gown and glove use for care involving feeding tubes. The LPN initially stated the resident was not on enhanced barrier precautions but later acknowledged that a gown should have been worn. The Director of Nursing confirmed that the resident should have been on enhanced barrier precautions and that staff needed retraining on the policy.