Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability for Residents With Wounds
Penalty
Summary
Facility staff failed to implement their Enhanced Barrier Precautions (EBP) policy for residents with wounds and indwelling devices, resulting in improper use of personal protective equipment (PPE) and lack of readily available PPE. The facility’s March 2024 EBP guidance required gown and gloves for high-contact resident care activities, including transfers and wound care, for residents with wounds or indwelling medical devices, and required PPE to be kept in proximity to the resident’s room with a trash can in the room for disposal. Surveyors found that these requirements were not followed for multiple residents with unhealed Stage III pressure ulcers. For one resident with cognitive impairment, dependence on staff for transfers, and an unhealed Stage III pressure ulcer, surveyors observed a CNA and a CMT enter the room to transfer the resident from bed to a shower chair. Although a sign on the door indicated EBP were required for high-contact care, there was no PPE in proximity to the room. The CNA and CMT donned only gloves, placed a mechanical lift sling under the resident, and transferred the resident without wearing gowns, despite direct contact and the presence of a wound on the upper buttocks. In interviews, the CMT stated EBP are used for residents with catheters, colostomies, or wounds and acknowledged a gown and gloves should have been worn, but said they did not know the resident had a wound and did not see the sign. The CNA stated gowns and gloves are used if staff are told the resident needs them, believed EBP were only needed for certain infections such as C. difficile, shingles, or MRSA, and said the sign on the door was old and did not apply. Surveyors also identified failures to ensure PPE availability for two additional residents with unhealed Stage III pressure ulcers. For one cognitively intact resident who reported having a wound on the bottom, a sign on the door indicated EBP were required for high-contact care, but no PPE was observed in proximity to the room or on a rack inside the room. For another cognitively intact resident who reported wounds on the legs and feet, a similar EBP sign was posted, yet no PPE was available near the door or on a rack inside the room. The DON and the Infection Preventionist confirmed in interviews that EBP should be used for residents with wounds or indwelling devices, that signs should be posted on doors, and that PPE should be available at or on the door, but acknowledged that staff were not using appropriate PPE and that PPE was not in place as required.
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