Failure to Ensure Staff Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff consistently followed infection prevention and control protocols, specifically Enhanced Barrier Precautions (EBP), when providing care to a resident with multiple risk factors for infection. On the date in question, two CNAs provided incontinent care to a resident who had a Foley catheter, gastrostomy tube, and a wound, without wearing the required personal protective equipment (PPE). This was confirmed through photo evidence submitted by a responsible party, which showed the staff members not wearing PPE during the care activity. Both CNAs had completed EBP training prior to the incident, and facility records indicated that PPE was available and that signage and supplies were in place to support compliance with EBP protocols. The resident involved was an older male with significant medical complexity, including end stage renal disease, osteomyelitis, heart failure, neuromuscular bladder dysfunction, a gastrostomy, peripheral vascular disease, and a below-the-knee amputation. He was dependent on staff for most activities of daily living, including toileting and mobility, and was unable to complete a BIMS assessment. The care plan and physician orders specified that the resident was to be on EBP due to his Foley catheter, gastrostomy tube, and chronic wounds, with interventions including staff and family education, signage, and ready access to PPE. Interviews with staff revealed inconsistent understanding and application of EBP protocols. One CNA could not recall if PPE was worn during the incident and admitted to not always using PPE, while the other CNA demonstrated a lack of understanding regarding when gowns were required. Other staff, including the ADON, DON, and additional CNAs, acknowledged the importance of EBP and the availability of PPE, but also noted ongoing challenges with staff compliance despite repeated in-servicing. Facility policy required PPE use for high-contact care activities for residents on EBP, but the observed failure to follow these protocols led to the identified deficiency.