Failure to Use Required PPE During Enhanced Barrier Precautions Transfer
Penalty
Summary
Facility staff failed to maintain the infection prevention and control program for one resident on Enhanced Barrier Precautions (EBP) by not using all required personal protective equipment (PPE) during a high-contact care activity. Resident #7 had diagnoses including end stage renal disease, type 2 diabetes with chronic kidney disease, and dependence on renal dialysis, and was cognitively intact with a BIMS score of 15/15. The resident had a medical provider order for Enhanced Barrier Precautions every shift related to hemodialysis and an AV fistula in the right forearm, and the comprehensive care plan included a focus on EBP with interventions specifying appropriate PPE per policy and isolation precautions per order. On the survey date, an EBP sign was posted on the resident’s door stating that a gown was required during high-contact patient care activities such as transferring. The surveyor observed two CNAs transferring Resident #7 from a geri-chair to the bed while wearing gloves but not gowns. When questioned, one CNA stated he usually wears a gown, and the other CNA stated she was just helping with the transfer. The LPN who reviewed the EBP sign agreed that gowns should have been donned for this activity. The facility’s EBP policy, effective 3/26/24, required the use of gowns by staff during high-contact care activities, including transferring, for patients who meet EBP criteria, such as those with indwelling medical devices. These observations and document reviews showed that staff did not follow the facility’s EBP policy and the resident’s care plan regarding required PPE.
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