F0880

D

Failure to Follow PPE Protocols for Residents on Enhanced Barrier Precautions

Chicago, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control program related to proper use and disposal of PPE for residents on Enhanced Barrier Precautions (EBP). One resident, identified as R42, had diagnoses including cellulitis of the right lower limb, lymphedema, and sepsis, with physician orders for midline insertion, wound care to the right knee and right lower leg, and IV therapy, and was placed on EBP. The care plan documented right lower extremity cellulitis with open wounds and antibiotic therapy for cellulitis on both lower extremities. On 01/13/26 at 11:35 AM, a registered nurse (V16) exited this resident’s room still wearing PPE, removed the PPE in the hallway, and placed it in a hamper located in the hallway. V16 stated that the resident was on isolation for a wound and described a practice of removing PPE outside the resident’s room, including for COVID rooms, contrary to facility policy and EBP expectations.

A second deficiency was identified involving another resident, R69, who had diagnoses including metabolic encephalopathy, dementia, and adult failure to thrive, with physician orders for sacral wound care and EBP. The care plan documented impaired skin integrity related to a pressure ulcer on the sacrum and left buttock excoriation. On 01/13/26 at 11:50 AM, a CNA (V18) was observed entering R69’s room carrying linen without donning PPE, despite EBP signage posted on the door. The surveyor observed V18 making the resident’s bed without wearing a gown and gloves. When questioned, V18 acknowledged that a gown and gloves should be worn when changing linen for a resident on EBP and stated there was a potential for infection and transmission between residents.

Interviews with other staff and review of facility policies confirmed that the observed practices did not align with established procedures. A CNA (V17) stated that for isolation or EBP rooms, PPE should be donned before entering and discarded inside the resident’s room. The Quality Director/Infection Preventionist (V14) described the expected donning and doffing sequence, emphasizing that gowns and gloves must be removed and discarded inside the resident’s room before exiting, and that gown and glove use is required for high-contact resident care activities such as changing linen, incontinence care, wound care, and IV care under EBP. Facility policies on infection prevention, standard and transmission-based precautions, PPE use, and EBP specified that PPE is to be removed and discarded before leaving the resident’s room and that gown and glove use is required for high-contact activities, including changing linens, with disposal of used PPE in receptacles located inside the room. The observed staff actions with R42 and R69 were inconsistent with these policies and expectations.