Failure to Ensure Proper PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). Surveyors observed multiple instances where staff did not wear the required gowns and gloves during high-contact care activities for residents with wounds, indwelling devices, or recent surgeries. For example, during direct care activities such as transferring, catheter care, clothing changes, and colostomy care, several staff members either wore only gloves or did not wear any PPE, despite clear signage on residents' doors indicating the need for both gowns and gloves. Residents involved in these deficiencies included individuals with indwelling urinary catheters, surgical wounds with staples, and multiple wounds with devices such as colostomies and intravenous lines. Staff members, including CNAs, a physical therapy assistant, and an unidentified nursing staff member, were observed providing direct care without adhering to the required PPE protocols. In some cases, staff expressed uncertainty or lack of knowledge about the necessity of wearing gowns in addition to gloves, or believed PPE was only needed for certain tasks, despite the residents' high risk for infection due to their medical conditions. Interviews with staff, including RNs, CNAs, the LPN, the DON, and the infection preventionist, revealed gaps in understanding and communication regarding EBP requirements. Some staff were unsure about the specific PPE needed for residents on EBP, while others acknowledged they should have worn gowns but failed to do so. The infection preventionist and DON confirmed that education on EBP and PPE use was provided, but the observed lapses indicated inconsistent adherence to infection control protocols during resident care activities.