Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident who was on enhanced barrier precautions (EBP) due to wounds and a urinary catheter. Observations showed that on multiple occasions, staff members transferred the resident between bed and wheelchair without wearing the required gown and gloves, despite clear signage indicating the need for PPE and the presence of PPE supplies nearby. Interviews revealed that some staff were unfamiliar with the residents on EBP, did not notice the signage, or did not understand the meaning of EBP, leading to lapses in infection control practices. The resident involved was an elderly female with a history of leg fracture with surgical repair, dementia, and kidney failure, requiring assistance with activities of daily living and placed on isolation precautions for a surgical wound. The facility had several residents on isolation for various reasons, and signage was used to indicate EBP status. Staff interviews indicated inconsistent knowledge and adherence to PPE protocols, and the Director of Nursing confirmed that while in-services on infection control were provided, there was no monitoring to ensure staff compliance with PPE use.