Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to wear appropriate personal protective equipment (PPE) while performing wound care on a resident who was under Enhanced Barrier Precautions (EBP). During the observation, the LVN was seen providing wound care with only gloves and without a gown, despite the presence of an EBP sign and a PPE cart outside the resident's room. The LVN later acknowledged that both a gown and gloves were required for such procedures under EBP and admitted to forgetting to wear the gown. The resident involved had multiple complex medical conditions, including sepsis, urinary tract infection, neurogenic bladder dysfunction, atrial fibrillation, and acute embolism and thrombosis of the lower extremity. The resident had several invasive devices, such as a PICC line, Foley catheter, and colostomy, and was receiving wound care for multiple wounds, including those on the sacrum, buttocks, and right foot. Physician orders and the facility's policy required EBP, which mandates the use of gown and gloves during high-contact care activities like wound care for residents with indwelling medical devices or wounds. Interviews with the LVN and the Director of Nursing (DON) confirmed that staff were trained to use gowns and gloves for residents on EBP during treatments. The facility's policy on EBP, reviewed by surveyors, specified that enhanced barrier precautions are to be implemented for residents with wounds or indwelling medical devices and that adherence is monitored by the Infection Preventionist. Despite these requirements, the observed failure to use the required PPE during wound care constituted a breach of the facility's infection prevention and control program.