Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Certified Nurse Assistants (CNAs) failed to wear the required gowns while providing direct care, including indwelling urinary catheter care and perineal care, to a resident on Enhanced Barrier Precautions (EBP) due to a history of Multi Drug Resistant Organism (MDRO) and the presence of an indwelling urinary catheter. During the observed care, the CNAs did not don gowns as required by facility policy, despite signage indicating EBP precautions outside the resident's room. Additionally, one CNA emptied the resident's urinary drainage bag without wearing a gown. The room lacked appropriate disposal bins for contaminated Personal Protective Equipment (PPE), and no disposed PPE was found in the room's garbage cans. Both CNAs acknowledged after the incident that gowns should have been worn during these care activities. The Assistant Director of Nursing/Infection Preventionist confirmed that staff are expected to use appropriate PPE, including gowns and gloves, when providing high-contact care to residents on EBP, particularly those with a history of MDRO and indwelling devices. Facility policy specifies that gown and glove use is required during high-contact activities such as hygiene care and care involving indwelling medical devices.