Failure to Use Required PPE for Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for two residents on EBP. Both residents had active wound care orders and posted EBP signage on their doors instructing staff to don gown and gloves for high-contact resident care activities such as dressing, changing linens, toileting/brief changes, and wound care. For Resident #1, a male with vascular dementia, scabies history, dermatitis, and a non-pressure wound on the right upper back requiring Xeroform and calcium dressing three times weekly, staff did not follow these requirements during observed care. On the survey date, the surveyor observed an EBP sign on Resident #1’s door and entered the room while CNA A was providing peri care without a gown. The ADON and a PRN-TN then entered and provided wound care to Resident #1’s back while CNA A assisted with positioning and transferring the resident to bed and reported changing the resident’s linens, all without wearing gowns. Only gloves and hand hygiene were used. No gowns were available in or outside Resident #1’s room despite the posted EBP instructions requiring gown and gloves for peri care, transfers, changing linens, and wound care. In interviews, CNA A stated he did not wear a gown because he believed the resident did not have a contagious infection or virus and did not think a gown was needed, although he acknowledged infection control training. For Resident #2, a female with primary progressive multiple sclerosis, an acute upper respiratory infection, and a sacral pressure wound requiring daily dressing changes, the care plan and orders specified EBP related to urinary catheter and wound care, with interventions stating staff must don gown and gloves for high-contact activities including dressing, bathing, transfers, hygiene, changing linens, toileting/brief changes, device care, and wound care. An EBP sign with these instructions was posted on her door. During observation, the surveyor noted there were no gowns in or outside the room. CNA B provided peri care without a gown, and later the ADON and PRN-TN performed sacral wound care wearing only gloves and performing hand hygiene, but without gowns. CNA B acknowledged changing the resident without a gown, stating the gown was not in the room and that she usually wore one. The PRN-TN stated she associated gown use primarily with residents having COVID-19 or respiratory conditions, despite having infection control training, and recognized that staff could transmit germs on their clothes. Resident #2 reported that staff usually wore gowns for wound and peri care and believed CNA B was rushed and forgot.
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