Failure to Use PPE During Resident Transfer Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to don appropriate Personal Protective Equipment (PPE), specifically a gown and gloves, prior to assisting a resident with a transfer into bed. The resident in question had an abscess in the right groin and was under Enhanced Barrier Precautions (EBP) as documented in the care plan. The CNA assisted the resident without PPE, despite facility policy and CDC guidelines requiring gown and glove use for high-contact activities such as transferring residents with wounds. The CNA confirmed during an interview that she did not wear PPE for the transfer, stating she believed PPE was only necessary for wound care or dressing changes. Review of the facility's EBP policy and CDC guidance indicated that PPE should be used for all high-contact care activities, including transfers, for residents with wounds. This lapse was observed and verified through medical record review, staff interview, and policy review.