Failure to Implement PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to implement the required Personal Protective Equipment (PPE) protocols for a resident with a history of multidrug resistant organism (MDRO) infection, as outlined in the facility's Enhanced Barrier Precautions (EBP) policy. The policy required staff to wear gowns and gloves during high-contact care activities, such as bathing and changing linens, for residents on EBP. Observations revealed that a nursing assistant provided a whirlpool bath to the resident without wearing any PPE, despite signage indicating the need for gowns and gloves. Additionally, another nursing assistant was observed removing the resident's bed linens without wearing a gown or gloves, and carried the linens against her uniform when exiting the room. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the resident was on EBP due to an MDRO in the urine and that PPE should have been used during these care activities. The staff involved acknowledged that PPE was not worn as required during both bathing and linen changes. The resident required partial to extensive assistance with bathing and had EBP in place due to their infection history.