Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols for a resident who required Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including a cerebral aneurysm, hemiplegia, dysarthria, and a dysfunctional bladder. The resident's care plan and facility policy required staff to wear gowns and gloves during high-contact care activities, such as tube feeding and catheter care, to prevent the transmission of multidrug-resistant organisms (MDROs). Despite clear signage and documented requirements, staff were observed performing these high-contact activities without donning gowns. Specifically, a nurse was seen changing the resident's tube feeding without a gown, and a CNA handled the resident's catheter bag and privacy cover without appropriate PPE. The Assistant Director of Nursing was present during one of these incidents and acknowledged the lapse, subsequently educating the staff involved. The deficiency was identified through direct observation, interviews, and review of the resident's records, which confirmed that the required infection control measures were not consistently implemented during resident care.