Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for a resident who was under Enhanced Barrier Precautions (EBP) due to a stage IV pressure ulcer and an indwelling catheter. Specifically, observation revealed that a Certified Nursing Assistant (CNA) exited the resident's area after changing the resident's brief and performing peri-care without wearing a gown, which is required under EBP for high-contact care activities. The CNA confirmed during an interview that neither they nor the assisting CNA wore a gown during the procedure, despite being aware of the EBP requirements. Record review showed that the resident had significant medical conditions, including active primary progressive multiple sclerosis and epilepsy, and had an active physician order for EBP. Facility policy and CDC guidance both require the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices. The failure to use appropriate PPE during these activities constituted a breach of the facility's infection control policy and CDC recommendations.