Failure to Ensure Proper PPE and Hand Hygiene During Enhanced Barrier Precautions
Penalty
Summary
Staff members failed to use appropriate Personal Protective Equipment (PPE) when providing care to residents requiring Enhanced Barrier Precautions (EBP). In one instance, a CNA assisted a resident with a urinary catheter and intravenous line into the bathroom while only wearing gloves and not a protective gown, despite signage and care plans indicating EBP was required. The Director of Nursing observed this lapse and confirmed that a gown should have been worn. The CNA exited the bathroom with a soiled brief in a clear garbage bag for disposal, still without the required gown. In another case, a CNA assisted a resident with an indwelling urinary catheter who required EBP, but only wore gloves and a mask, omitting the protective gown. The CNA was also unsure which resident required EBP and, after changing a urinary drainage leg bag, exited the room still wearing gloves, removed them in the hallway, and failed to perform hand hygiene before proceeding to the nurses' desk. Both residents involved had diagnoses including urinary tract infections and required EBP for high-contact care, as documented in their care plans. Facility policies required the use of gowns and gloves for EBP and mandated hand hygiene before and after resident contact and glove removal.