Failure to Discard PPE Before Exiting EBP Room
Penalty
Summary
The facility failed to ensure proper disposal of personal protective equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP) for a resident with a right hip incision infection and a medical device to drain urine directly from the kidney. The resident was cognitively intact and had care orders and a care plan specifying the use of disposable gloves and gowns during high-contact care. During an observation, two registered nurses donned gowns and gloves before providing care, but one nurse left the resident's room wearing the same PPE to retrieve additional supplies from a supply closet and then returned to the room. The nurse later disposed of her gown in a hallway garbage can rather than inside the resident's room. Interviews with both nurses confirmed that supplies for EBP should be stored inside the resident's room and that PPE should be discarded before exiting the room to prevent the transmission of bacteria. Both nurses acknowledged the error and stated that used PPE could have been contaminated. Facility policy required the infection prevention and control program to prevent the transmission of diseases and infections, but this protocol was not followed during the observed incident.