Failure to Use Required PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a physical therapist (PT) failed to follow infection control practices by not wearing an isolation gown while providing in-bed physical therapy services to a resident who was on enhanced barrier precautions (EBP) due to an indwelling catheter and a multidrug-resistant organism (MDRO) infection. The resident had a history of right femur fracture, urinary tract infection, and extended spectrum beta-lactamase (ESBL) producing bacteria, and was dependent on staff for multiple activities of daily living. Facility records and signage indicated that gown and gloves were required for high-contact care activities under EBP. During direct observation, the PT was seen wearing only gloves and a surgical mask while performing range of motion exercises and repositioning the resident, despite EBP signage posted at the room entrance. The infection preventionist and the director of nursing both confirmed that an isolation gown should have been worn for such high-contact activities. The facility's infection control policy also specified the use of gown and gloves for high-contact care under EBP to prevent the spread of MDROs.