Failure to Provide PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified that the facility failed to provide sufficient personal protective equipment (PPE) for residents requiring Enhanced Barrier Precautions (EBP), specifically affecting four residents identified in facility documentation as needing EBP due to a gastrostomy tube or wounds. The facility’s EBP policy, revised in 9/2023, and an EBP document dated 8/2025 indicated that residents with multidrug-resistant organisms (MDRO) or at increased risk of acquiring MDRO require gown and glove use during high-contact resident care activities. On 8/11/2025, signage on the doors of the rooms for these residents indicated that gloves and gowns were required when performing resident care. However, during observation of the 2400 unit, only one isolation bin was present and it contained no gowns, and no other PPE was available on the unit. A CNA assigned to the 2400 unit confirmed that there were no gowns available for residents on EBP and stated they would not be able to care for the residents properly without a gown and gloves, which are required to provide care under EBP. The DON later affirmed that the facility’s expectation is that PPE be readily available for staff as indicated by resident needs.
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