Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier infection control procedures and ensure the proper use of personal protective equipment (PPE) for one resident with chronic kidney disease and peripheral vascular disease, who had a sacral wound requiring enhanced barrier precautions. Despite a physician's order for these precautions, staff were observed using hospital gowns instead of the designated reusable gowns intended for this purpose. The facility policy required the use of specific gowns and gloves during high-contact care activities, but this was not followed during care provided after the resident experienced a fall. Further investigation revealed that staff had not received adequate education regarding the correct selection and use of PPE, specifically the designated color of gowns for enhanced barrier precautions. The Director of Nursing confirmed that reusable gowns were to be used, and that the use of hospital gowns was not appropriate. Additionally, the facility lacked a system for laundering, maintaining, and storing the reusable gowns as required by CDC recommendations. These failures resulted in the ineffective implementation of enhanced barrier precautions for the resident.