Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program for a resident on enhanced barrier precautions. The resident was an adult female with cervical spina bifida and paraplegia, with intact cognition and an indwelling urinary catheter. Her comprehensive care plan documented that she was on enhanced barrier precautions, with interventions requiring staff to don both gown and gloves for high-contact care activities such as linen changes, resident hygiene, transfers, dressing, toileting/incontinence care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activities. An enhanced barrier precaution sign was posted at the room entrance instructing staff to wear a gown and gloves during incontinence care, and a plastic cabinet with drawers containing PPE was located outside the room. On the observed date and time, a CNA exited the resident’s room and reported she had just provided incontinence care. When questioned, the CNA stated she wore gloves but not a gown and believed a gown was only required if the resident had a certain type of infection or an infected wound, despite the posted sign specifying gown and glove use for incontinence care and the resident’s known urinary catheter. The resident reported that some staff wore a gown and gloves during incontinence care and some did not. Nursing staff, including an LVN and the ADON, stated that the resident was on enhanced barrier precautions due to the urinary catheter and confirmed that staff should wear appropriate PPE, including a gown and gloves, when providing incontinence care to prevent cross-contamination. The facility’s written Enhanced Barrier Precautions policy required targeted gown and glove use during high-contact resident care activities for residents with wounds and/or indwelling medical devices, including urinary catheters.
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.