Failure to Use Required PPE During High-Risk Resident Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols for a resident with significant medical needs, including chronic wounds and an indwelling Foley catheter. During direct care activities, including Foley catheter care and wound dressing changes, the Assistant Director of Nursing (ADON), a Certified Nursing Assistant (CNA), and a Registered Nurse (RN) entered the resident's room without donning the required disposable gowns, despite clear signage and the availability of personal protective equipment (PPE) at the entrance. All three staff members only wore gloves while providing care, contrary to the facility's Enhanced Barrier Precautions policy, which mandates both gowns and gloves for high-contact care activities involving residents with wounds or indwelling devices. The resident involved had a complex medical history, including paraplegia, chronic wounds to the sacrum and right lower ischium, an intraspinal abscess, osteomyelitis, and an indwelling Foley catheter. The care plan and physician orders specified the need for enhanced infection control measures, and the resident's room was clearly marked with instructions for staff to use gowns and gloves. Observations confirmed that the required PPE was available outside the room, and the staff acknowledged during interviews that they were aware of the need for full PPE but failed to comply due to distraction or forgetfulness. Facility policy, as well as the revised Enhanced Barrier Precautions guidelines, require the use of gowns and gloves during high-contact care for residents with chronic wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. The staff's failure to adhere to these protocols was confirmed through observation, interviews, and record review, and was acknowledged by the Director of Nursing as a breach of infection control standards.