Failure to Use Required PPE for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently used required personal protective equipment (PPE) for residents on contact precautions and enhanced barrier precautions (EBP). Resident #10, admitted with a history including a local skin and subcutaneous tissue infection and extended spectrum beta lactamase (ESBL) resistance, had active orders and a care plan for contact precautions related to an ESBL wound infection, directing staff to use appropriate PPE and maintain isolation precautions. A contact isolation sign was posted on the resident’s door. During observation, an LPN entered the resident’s room without a gown or gloves, stood next to the resident’s bed, and stated she believed PPE was only required if she was providing care. After reviewing the posted contact isolation information, the LPN acknowledged she should have donned a gown and gloves before entering. The ADON, DON, and Administrator each stated that staff were required to wear a gown and gloves whenever entering the room of a resident on contact isolation, even if only asking a question. The facility also did not ensure proper PPE use for Resident #12, who had an indwelling urinary catheter and a surgical wound, with active orders for EBP every shift and a care plan indicating the need for EBP. During observation, a GNA and an LPN transferred the resident from bed to wheelchair using a mechanical lift while wearing gloves but no gowns. The LPN later stated that EBP should be used, including PPE, when caring for residents with urinary catheters and acknowledged she should have stopped the transfer to put on a gown upon seeing the catheter. The GNA stated that residents with wounds, infections, feeding tubes, or catheters required EBP and that a gown and gloves were to be worn when providing care. The ADON, DON, and Administrator each confirmed that EBP, including both gown and gloves, was required when providing care, such as transfers, to residents with devices like indwelling urinary catheters or wounds, and that staff were expected to follow the PPE requirements listed on signage.
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