F0880

D

Failure to Use Required PPE for Resident on Enhanced Barrier Precautions

Cincinnati, Ohio Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow the infection prevention and control program by not using required personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted on 01/04/26 with diagnoses including encephalopathy, sleep apnea, heart failure, and severe sepsis, and had no cognitive deficits but required staff assistance with ADLs. A physician’s order dated 01/07/26 placed the resident on EBP due to the presence of an enteral tube and wounds. On 02/09/26 at 9:23 A.M., during observation of medication administration via gastrostomy tube, an LPN provided care without wearing a gown or gloves. In a subsequent interview, the LPN confirmed she was not wearing a gown or gloves, acknowledged the resident was on EBP, and stated she should have donned a gown and gloves prior to administering the medication. Review of the facility’s Enhanced Barrier Precautions policy dated 07/30/25 showed the facility would implement EBP as appropriate for prevention of transmission of multidrug-resistant organisms.

These findings demonstrate that, despite an active EBP order and a facility policy requiring implementation of EBP, staff did not consistently wear appropriate PPE while providing care involving an enteral tube to a resident under EBP.