Failure to Use PPE During Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A certified nursing assistant (CNA) failed to follow established infection prevention and control protocols while providing toileting care to a male resident with a stage 4 sacral pressure ulcer who was on Enhanced Barrier Precautions (EBP). The resident's medical record indicated an active physician order requiring staff to wear a clean gown and gloves during high-contact care activities, including toileting, due to the presence of a wound. The resident's care plan also documented the need for EBP. During an observed care episode, the CNA did not don any personal protective equipment (PPE) despite a posted EBP sign on the resident's door. Upon interview, the CNA acknowledged forgetting to wear PPE and was aware of the resident's wound and EBP status. The assistant director of nursing (ADON) confirmed that the expectation was for staff to adhere to infection control policies, including the use of PPE for residents on EBP. The facility's policy required EBP for activities such as bathing, hygiene, and toileting for residents with indicated precautions.