Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection control program by not ensuring that a Restorative Nurse Assistant (RNA) used proper personal protective equipment (PPE) during high-contact care for a resident on enhanced barrier precautions (EBP). Specifically, the RNA assisted a resident with passive range of motion (PROM) exercises for the lower extremities without wearing an isolation gown, despite the resident having a chronic stage four pressure ulcer and an indwelling catheter, both of which require EBP during high-contact activities. The resident's care plan and physician's orders clearly indicated the need for EBP, including gown and glove use during such activities, to prevent the spread of multidrug-resistant organisms (MDROs). Interviews with the RNA, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that the RNA did not follow the facility's EBP policy, which mandates gown and glove use during high-contact care for residents with wounds or indwelling devices. The RNA incorrectly believed that gowns were only necessary for wound or catheter care, not for restorative care activities. The facility's policy, last reviewed in May 2025, explicitly lists restorative care as a high-contact activity requiring EBP. This failure to adhere to established infection control protocols had the potential to contribute to the spread of MDROs among residents.