Failure to Doff PPE and Perform Hand Hygiene Exiting EBP Room
Penalty
Summary
Restorative Nurse Assistant 1 (RNA 1) failed to properly remove personal protective equipment (PPE) and perform hand hygiene when exiting the room of a resident who was on Enhanced Barrier Precautions (EBP). The resident in question had multiple diagnoses, including end-stage renal disease, dependence on dialysis, type 2 diabetes, and pressure ulcers, and was on EBP due to the presence of a dialysis port and a recent lower extremity amputation. Facility policy and posted signage required staff to don PPE before entering and doff PPE and perform hand hygiene before exiting the resident's room. On the day of the incident, RNA 1 was observed exiting the resident's room wearing gloves and a gown, walking into the hallway to retrieve an oxygen tank, and then re-entering the room without removing PPE or performing hand hygiene. This action was contrary to the facility's infection prevention and control policy, which was confirmed by interviews with the Registered Nurse Supervisor, Director of Quality Assurance, and Chief Clinical Officer. All confirmed that PPE should be removed and hand hygiene performed prior to leaving the resident's room to prevent the spread of infection. RNA 1 acknowledged during an interview that she failed to remove her PPE and perform hand hygiene before exiting the room, stating she was focused on retrieving the oxygen tank and did not realize her mistake until after the fact. The facility's policy, as reviewed, clearly outlined the steps for PPE use and removal in accordance with EBP and standard precautions, emphasizing the importance of these measures in preventing cross-contamination and the spread of multidrug-resistant organisms.