Failure to Consistently Use Isolation Gowns During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently utilize required isolation gowns when providing care to a resident on Enhanced Barrier Precautions (EBP) due to a pressure ulcer and risk of multi-drug resistant organism transmission. The resident was cognitively intact, dependent on staff for toileting and transfers, and required substantial assistance with activities of daily living. The care plan and facility policy specified that staff must wear gowns and gloves during high-contact care activities, including dressing, bathing, toileting, and wound care. During observations, some staff members wore both gowns and gloves as required, but a CNA was observed providing care with only gloves and no gown during a shower and while drying the resident's back. The CNA acknowledged forgetting to don a new gown after removing the previous one. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves for this resident under EBP, in accordance with facility policy.