Failure to Use Required PPE During Pressure Ulcer Dressing Change
Penalty
Summary
Staff failed to don the appropriate personal protective equipment (PPE) during a pressure ulcer dressing change for one resident who was under enhanced barrier precautions (EBP). Specifically, during an observed dressing change to a stage 4 pressure ulcer, neither the LPN nor the CNA wore a gown, despite facility policy and signage indicating that both gloves and gowns were required for high-contact care activities under EBP. The PPE bin and signage were present outside the resident's room, clearly stating the need for gown and glove use, but these were not followed during the procedure. The resident involved had a history of paraplegia, a stage 4 pressure ulcer, above the knee amputation, and heart failure, and was cognitively intact according to the most recent assessment. Physician orders required regular dressing changes to the ischium wound. The Director of Nursing/Infection Preventionist confirmed that the expectation was for staff to wear gowns during dressing changes for residents on EBP, which was not adhered to in this instance.