Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). On the observed date, an LPN and a CNA performed wound care and peri care for a resident with an open wound and a Foley catheter without wearing gowns, despite an EBP sign posted on the door and orders in the resident's chart indicating the need for EBP. During the procedure, a unit manager also entered the room and did not observe the staff wearing gowns. Interviews with the involved staff confirmed their awareness that gowns should have been worn during high-contact care activities for residents on EBP. The resident involved had a history of urinary tract infection, osteomyelitis, a stage IV pressure ulcer, unspecified injury at C4, and neurogenic bowel, and was cognitively intact according to the most recent assessment. Facility policy required the use of PPE, including gowns, during high-contact care activities such as wound care and device care for residents on EBP. The Director of Nursing acknowledged that staff did not follow posted signs or physician orders regarding EBP during the incident.