Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident requiring enhanced barrier precautions. During observation, two CNAs were seen providing care and changing linens for a resident with a feeding tube, wearing only gloves and not gowns, despite PPE supplies being available at the door. Additionally, an LPN entered the same resident's room to perform feeding tube site care, using hand hygiene and gloves but not donning a gown as required by the facility's enhanced barrier precautions policy. The policy specifies that both gown and gloves are necessary for high-contact care activities, including feeding tube care, wound care, and changing linens for residents at increased risk of MDRO acquisition. Record review showed the resident had severely impaired cognition, a feeding tube, and physician orders for enhanced barrier precautions related to wound, colostomy, and indwelling catheter care. Interviews with staff revealed inconsistent understanding and implementation of the enhanced barrier precautions policy, with the LPN stating that only gloves were used for feeding tube care and gowns were reserved for other activities. The infection prevention nurse confirmed that both gown and gloves should be used for all high-contact care activities, including feeding tube site care, indicating a failure to follow established infection control protocols.