Failure to Adhere to PPE Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to proper use of personal protective equipment (PPE) during wound care for residents on enhanced barrier precautions. For one resident with Type 1 Diabetes and Peripheral Vascular Disease, staff did not don gloves or gowns while exposing and observing a wound, despite the care plan specifying enhanced barrier precautions. The staff involved admitted to forgetting or misunderstanding the need for PPE, even though the resident had an open wound and was on enhanced barrier precautions. In additional observations, staff did not follow correct procedures for removing PPE after providing wound care to two other residents with cognitive impairments and vascular dementia. Specifically, staff removed gloves and gowns in a manner that could lead to contamination, such as touching the front of the gown with bare hands and not following recommended glove removal techniques. Interviews with staff and administration confirmed a lack of adherence to established protocols for donning and doffing PPE, with staff acknowledging the importance of these practices but failing to implement them correctly during care. The facility's own infection control policy and CDC guidelines were not followed, as staff did not consistently wear or remove PPE as required when providing care to residents with wounds or indwelling devices. The Director of Nursing and Assistant Director of Nursing both recognized the correct procedures and the necessity of PPE use, but these were not observed in practice during the survey. The deficiency was identified through direct observation, interviews, and record review, demonstrating a breakdown in infection control practices for multiple residents.