Failure to Use Required PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff failure to don required personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). Four residents on EBP were involved: one with tracheostomy, ventilator dependence, gastrostomy tube, urinary catheter, and a history of carbapenem-resistant Acinetobacter baumannii; one with acute and chronic respiratory failure, ventilator dependence, pneumonia due to Klebsiella pneumoniae, tracheostomy, and gastrostomy; one with surgical aftercare needs and type 2 diabetes mellitus with complications; and one with tracheostomy, gastrostomy, cognitive communication deficit, multiple indwelling devices and wounds, and a known history of multiple multidrug-resistant organisms (MDROs) and C. difficile. All four residents were on EBP transmission-based protocols due to wounds, trachs, vents, G-tubes, urinary catheters, and/or MDRO history. On multiple observations on the same day, a CNA entered the rooms of these residents and provided direct care without wearing a gown, despite EBP signage and PPE supplies being present at the room entrances. For one resident, the CNA entered to reposition and assist without donning a gown, wearing only gloves and a mask, and had direct contact with the resident during care. After wound care for another resident, the same CNA again entered that resident’s room without a gown to reposition the resident, provide clean linens, and cover the resident with a blanket, then removed gloves and performed hand hygiene before leaving. The CNA was also observed entering another resident’s room on EBP to provide patient care, including changing linens, wearing only gloves and a mask and again not donning a gown, despite posted EBP signage and available PPE. Interviews with facility staff confirmed that the facility’s expectation and policy required staff to wear gowns, gloves, and masks when providing direct care to residents on EBP, including activities such as suctioning trachs, G-tube feedings, changing linens, changing diapers, and wound care. The wound director, respiratory therapist, CNA, LPN, infection preventionist, and DON each stated that for residents on EBP, staff must don gown, gloves, and mask for direct care or high-contact resident care activities. Facility policies titled “Enhanced Barrier Precautions” and “Infection Prevention and Control Program” specified that EBP involves the use of gown and gloves for high-contact resident care activities for residents colonized or infected with MDROs or at increased risk of MDRO acquisition, and that gowns and gloves are to be worn for all interactions that may involve contact with the resident or the resident’s environment, with PPE donned upon room entry and discarded before exiting. The observed failure of the CNA to wear gowns during direct care to residents on EBP occurred in the context of these established policies and stated staff expectations.
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