Failure to Ensure Staff Use of PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) while providing care to two residents who were on enhanced barrier precautions (EBP) due to conditions such as chronic wounds, indwelling devices, and enteral feeding tubes. Facility policy required the use of gowns and gloves during high-contact care activities for residents on EBP. In one instance, three CNAs provided incontinence care to a resident with a stage IV sacral ulcer, suprapubic catheter, and gastrostomy tube. Only one CNA wore the required gown and gloves, while another wore only a mask and gloves, and the third wore only a mask. One CNA handled a urinary drainage bag without gloves. The CNAs were initially unable to explain the purpose of EBP but identified the reason after reading posted signage, and two acknowledged not wearing the required PPE. In another case, a resident with a chronic ulcer of the buttocks and an order for wound care was observed receiving a bed bath from a CNA who was not wearing a gown, despite EBP signage and available PPE outside the room. The CNA recognized that the resident was on EBP due to wounds and admitted forgetting to don the appropriate PPE during care. These observations were based on direct observation, record review, staff interviews, and review of facility policy.