Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow established infection prevention and control protocols while providing wound care to a resident. The resident, a female with diagnoses including endocarditis, type 2 diabetes, end stage renal failure, and hypertension, had a diabetic ulcer on her left heel. Facility records indicated an active order for enhanced barrier precautions, requiring staff to wear gloves and a gown during high-contact care activities. Despite clear signage on the resident's door and the availability of personal protective equipment (PPE) in the hallway, the LVN entered the resident's room and performed wound care without donning a gown. During interviews, the LVN acknowledged awareness of the requirement to wear both gloves and a gown when in contact with the resident, as per facility policy and the resident's care plan. The LVN admitted to not having a reason for failing to use the appropriate PPE, despite having access to it. The Director of Nursing (DON) confirmed that staff were expected to use PPE during wound care and that regular in-services on infection control and enhanced barrier precautions had been conducted. Facility policy reviewed also specified the use of gloves and gowns for high-contact care activities to prevent the spread of multi-drug resistant organisms.