Failure to Use Required PPE During High-Contact Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow enhanced barrier precautions while providing care to a resident with multiple complex medical conditions, including a stage III pressure ulcer. During observed episodes of incontinent care and a dressing change, certified nursing assistants and a licensed practical nurse wore gloves but did not don gowns, despite clear signage and care plan instructions requiring both gloves and gowns for high-contact activities under enhanced barrier precautions. The care plan and posted signage specified that gowns and gloves were necessary for activities such as changing briefs, providing hygiene, and wound care for residents on these precautions. The facility's policies, as well as statements from the unit manager, confirmed that staff are required to wear gowns and gloves when providing high-contact care to residents on enhanced barrier precautions. Documentation showed that the resident had an active order for wound care and was assessed with a stage III pressure ulcer. Despite these requirements and the presence of clear instructions, staff did not comply with the expected infection control protocols during the observed care events.