Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE), specifically gowns and gloves, was consistently used by staff during high-contact care activities for residents under enhanced barrier precautions (EBP). Observations revealed that staff members assisted residents with pressure ulcers and indwelling urinary catheters in activities such as transferring, changing briefs, and providing perineal hygiene without donning gowns, despite clear signage and facility policy requiring both gown and glove use for these activities. Staff interviews confirmed a lack of understanding or adherence to the EBP requirements, with some staff believing gowns were only necessary during morning care or for residents on isolation, and others indicating they could decide whether to use a gown during catheter care. The residents involved included one with diabetes and multiple unstageable pressure ulcers requiring dressing changes, and another with severe cognitive impairment, multiple chronic conditions, and an indwelling urinary catheter. Both residents had care plans and signage indicating the need for EBP, and PPE carts were available outside their rooms. Despite these measures, staff did not follow the required infection control protocols during observed care activities, as confirmed by interviews with the infection preventionist, LPN, and DON, all of whom stated that both gowns and gloves should be used for high-contact care under EBP.