Failure to Change PPE Between Residents on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established guidelines for the use of Personal Protective Equipment (PPE) when providing care to three residents who were on Enhanced Barrier Precautions (EBP) due to their medical conditions, including hemiplegia, encephalopathy, muscle weakness, and the presence of gastrostomy tubes. All three residents were severely cognitively impaired and totally dependent on staff for activities of daily living. Physician orders and facility policy required the use of gowns and gloves for high-contact care activities, with PPE to be changed and hand hygiene performed between contact with each resident, especially in multi-bed rooms where each bed space is considered a separate room. During an observation, a Certified Nursing Assistant (CNA) was seen wearing the same gown, mask, and gloves while sequentially checking and touching the gastrostomy tube sites of all three residents in the same room, without changing PPE or performing hand hygiene between residents. The Director of Nursing confirmed that staff were required to don and doff PPE appropriately for each resident on EBP and acknowledged that failure to do so could result in the transfer of infection between residents. Facility policy also specified the need to change gowns and gloves and perform hand hygiene when moving from contact with one resident to another in multi-bed rooms.