Failure to Use Proper PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper infection prevention and control protocols for a resident with a feeding tube who was on enhanced barrier precautions (EBP) due to increased risk of multidrug-resistant organism (MDRO) acquisition. The resident, who had oropharyngeal dysphagia following a stroke and was severely cognitively impaired, required EBP as indicated in the care plan and physician orders. The care plan specifically directed staff to don appropriate personal protective equipment (PPE), including gowns and gloves, prior to high-contact care activities such as incontinence care and feeding tube management. Despite these directives, observations revealed that a certified nursing assistant (CNA) and a licensed practical nurse (LPN) both provided high-contact care to the resident without wearing gowns, although gloves were used. The CNA provided incontinence care and the LPN administered medication via the feeding tube without donning gowns, contrary to facility policy and the resident's care plan. Both staff members acknowledged awareness of the EBP requirements but cited reasons such as forgetting or being nervous for not following protocol. Interviews with facility leadership confirmed that staff were expected to wear gowns during such care activities for residents on EBP.