Failure to Use Required PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow the infection prevention and control policy and physician orders for residents on Enhanced Barrier Precautions (EBP). One resident with hemiplegia, hemiparesis following cerebral infarction, gastrostomy status, aphasia, a G-tube, Foley catheter, and wounds had a care plan and physician order specifying EBP, including the use of gown and gloves for high-contact resident care activities such as bathing. An EBP sign was posted at the room entrance instructing providers and staff to wear gloves and a gown for high-contact activities including dressing, bathing/showering, changing linens, providing hygiene, changing briefs or assisting with toileting, and device care or use for urinary catheters and feeding tubes. During observation, a CNA was seen bathing this resident while wearing a face mask and gloves but not a gown, despite acknowledging awareness that the resident was on EBP and stating she had simply forgotten to wear the gown. Another resident, admitted with bilateral above-knee amputations, COPD, gout, osteoarthritis, hypertension, BPH, urinary retention, dysphagia, and a Stage IV pressure ulcer present on admission, also had an EBP sign posted outside the room. The sign directed that everyone must clean their hands before entering and when leaving, and that providers and staff must wear gloves and a gown for high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. During observation, a CNA was providing a bed bath and changing the resident’s gown while wearing gloves but no gown. The CNA completed the care, disposed of the soapy water in the sink, removed gloves, performed hand hygiene, and handled the dirty linens, but did not use a gown at any point during the high-contact care, despite later stating that proper PPE for bathing a resident on EBP includes both a gown and gloves.
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