Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols by not wearing required personal protective equipment (PPE) during high-contact care for a resident on Enhanced Barrier Precautions (EBP). Specifically, during an observed straight catheterization procedure, neither the LPN nor the Unit Manager donned an isolation gown, despite facility policy and CDC guidance requiring gown and glove use for such activities. The resident, who was cognitively intact and had diagnoses including Parkinson's disease and urinary retention, had physician orders for straight catheterization and EBP, which specified gown and glove use for high-contact care. Interviews revealed that staff routinely did not wear isolation gowns during straight catheterization, with the Unit Manager stating that gowns were only used if the resident had an infection. The Director of Nursing confirmed that staff should have worn an isolation gown for hands-on care in this situation. Review of facility policy and CDC guidance further supported the requirement for targeted gown and glove use during high-contact care for residents with indwelling devices or wounds, regardless of infection status.