Failure to Use Required PPE During Pressure Ulcer Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use the required personal protective equipment (PPE) while performing pressure ulcer treatment on a resident who was on enhanced barrier precautions. The resident had multiple medical conditions, including neuromuscular dysfunction of the bladder, constipation, orthostatic hypotension, a bacterial infection, cognitive communication deficit, and required assistance with all activities of daily living. The resident also had a suprapubic Foley catheter and was dependent on staff for care. The care plan indicated the need for staff to anticipate and meet all care needs, including maintaining cleanliness and comfort. On the day of the incident, the LVN entered the resident's room, which had signage indicating enhanced barrier precautions, and performed wound care without donning gown and gloves as required. The LVN later acknowledged forgetting to use PPE and recognized the importance of PPE in preventing infection. Facility policy and CDC guidelines both require the use of gown and gloves for high-contact care activities with residents on enhanced barrier precautions, particularly those with open wounds or indwelling medical devices. The facility's Director of Nursing confirmed that staff are trained on these precautions and that appropriate signage was posted in the resident's room.