Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when LVN B failed to don personal protective equipment (PPE) prior to performing a high-contact care activity for a resident on enhanced barrier precautions. Specifically, LVN B prepared and administered medication and tube feeding to a male resident with a history of bipolar disorder, hemiplegia, dysphagia, and gastronomy status, without wearing the required PPE. The resident's care plan and room signage indicated the need for enhanced barrier precautions, and a PPE cart was available outside the room. Despite this, LVN B only performed hand hygiene before entering the room and did not use gloves or a gown while accessing the resident's feeding tube. During interviews, LVN B acknowledged awareness of the resident's precaution status and admitted she should have donned PPE before providing care. She also recognized that failure to use PPE could put the resident at risk for infection. The DON confirmed that staff were expected to use appropriate PPE for residents on enhanced barrier precautions and that staff had been in-serviced on infection control protocols. Facility policy required the use of gloves and gowns for high-contact activities, including device care such as feeding tubes, but this protocol was not followed in this instance.