Failure to Use Required PPE During Care of Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nurse Assistants 1 and 2 failed to don the required personal protective equipment (PPE), specifically gowns, while providing care to a resident who was on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube and high risk for infection. During an observation, both CNAs were seen cleaning and changing the resident while only wearing gloves, despite the care plan and physician orders indicating the need for both gloves and gowns during high-contact care activities. The resident was dependent on staff for all activities of daily living and had severely impaired cognition, further increasing the risk of infection transmission. Interviews with the CNAs, Infection Prevention Nurse, and Director of Nursing confirmed that staff were aware of the requirement to wear gowns and gloves for residents on EBP, particularly those with feeding tubes. The facility's policy also specified the use of gowns and gloves during high-contact care for residents at increased risk of multidrug-resistant organism (MDRO) acquisition. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in infection prevention and control practices.