Failure to Provide Immediate PPE Access for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that ensured personal protective equipment (PPE) was immediately available near or outside the rooms of all residents on Enhanced Barrier Precautions (EBP). Observations revealed that while appropriate signage was present on the doors of rooms requiring EBP, PPE was not located at or near these rooms. Instead, PPE was stored in supply closets located on specific halls, requiring staff to leave the immediate area of the resident to obtain necessary equipment before performing high-contact activities. In contrast, rooms on contact precautions had PPE readily available at the door or next to the room. Interviews with staff, including the Assistant Directors of Nursing (ADONs), Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), Director of Nursing (DON), and Infection Control Nurse (ICN), confirmed that PPE for EBP was not kept near the residents' rooms but rather in supply closets. Staff expressed uncertainty regarding the specific requirements for PPE placement for EBP, with some believing that having PPE available anywhere in the facility was sufficient. Staff also reported that retrieving PPE from distant supply closets was tedious and time-consuming, and signage did not clearly instruct visitors on PPE use or where to obtain it. Review of the facility's policies and CDC guidelines indicated that gowns and gloves should be made available immediately near or outside the resident's room for EBP. However, the facility's practice did not align with these requirements, as PPE was not stored in the required locations. The deficiency affected all 13 residents on EBP, including those with wounds, indwelling medical devices, or certain infections, as PPE was not immediately accessible for high-contact care activities as stipulated by policy.