Failure to Use Required PPE During Wound Care for Resident on Contact Isolation
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to wear a gown while performing a wound vac dressing change for a resident who was on contact isolation due to methicillin-resistant Staphylococcus aureus (MRSA) in the nares and a right knee surgical wound. The resident's care plan and physician orders specified the need for contact isolation precautions, including the use of personal protective equipment (PPE) such as gloves and gowns during care. During the observed dressing change, the RN wore gloves but did not don a gown, despite the resident being on isolation for MRSA. Another RN, who entered the room to troubleshoot the wound vac, was observed wearing both a gown and gloves. The resident confirmed that the RN did not wear a gown during the dressing change. The Director of Nursing stated that both gown and gloves are required for close contact care to prevent contamination and infection. Facility policies on infection control, contact precautions, and enhanced barrier precautions all require the use of appropriate PPE, including gowns and gloves, during high-contact resident care activities such as wound care. Documentation showed the resident had a surgical wound with significant tunneling and a wound vac in place, requiring regular dressing changes.