Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols during the wound care of a resident with a facility-acquired pressure injury to the sacral area. During a surveyor's observation, CDC signage was posted outside the resident's room indicating that Enhanced Barrier Precautions (EBP) were required, including the use of gloves and gowns for high-contact resident care activities such as wound care. Despite these posted requirements, the LPN performing the wound treatment donned gloves but did not wear a disposable gown throughout the procedure. The LPN performed appropriate hand hygiene before, during, and after the wound care, but did not comply with the full PPE requirements as outlined by the CDC and facility signage. During an interview, both the Nursing Home Administrator and Director of Nursing acknowledged awareness that the LPN had not properly donned the required PPE while providing wound care. This failure to use the appropriate PPE during a high-contact procedure constituted a breach of the facility's infection prevention and control program.