Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) and infection prevention and control measures for three residents who required gown and glove use during high-contact care. Facility records showed that Residents 1 and 2 had quadriplegia and neuromuscular dysfunction of the bladder, with indwelling urinary catheters (a Foley catheter for Resident 1 and a suprapubic catheter for Resident 2). Their care plans and order summaries directed staff to follow EBP and to use gowns and gloves during high-contact activities to prevent MDRO infection. Resident 3 had a colostomy, cellulitis, diabetes mellitus, and severe cognitive impairment, with orders indicating EBP due to the colostomy. The facility’s EBP policy stated that gowns and gloves were required prior to high-contact care activities for residents with indwelling medical devices or wounds. Surveyors observed multiple instances where staff did not follow these requirements. In Resident 1’s room, CNA 1 was observed providing mobility assistance without wearing a gown or gloves, while their uniform, hands, and arms came into direct contact with the resident and the resident’s linens. For Resident 2, CNA 4 was observed feeding the resident breakfast without wearing a gown, despite the resident’s EBP status related to a suprapubic catheter and care plan instructions for gown and glove use during high-contact activities. These observations occurred even though both residents had documented orders and care plans specifying EBP and the need for PPE during high-contact care. For Resident 3, who had an order for EBP due to a colostomy, CNA 1 and CNA 3 were observed repositioning and moving the resident without wearing gowns and gloves, with their uniforms and hands touching the resident and linens. In a concurrent observation, CNA 3 was also seen feeding Resident 3 without a gown and gloves. The EBP informational sign posted for Resident 3 indicated that staff were required to wear gowns and gloves for all high-contact activities, including feeding and repositioning. During interviews, CNA 3, LVN 1, and the DON all confirmed that high-contact activities such as feeding, turning, and repositioning required gown and glove use under the facility’s EBP policy, and acknowledged that staff should have been wearing this PPE when providing care to these residents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.