Failure to Follow Enhanced Barrier Precautions and PPE Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff properly used personal protective equipment (PPE) in accordance with its Enhanced Barrier Precautions (EBP) policy for four residents on EBP. The facility’s policy IC308 required the use of gown and gloves during high-contact resident care activities to reduce the risk of transmission of multi-drug resistant organisms. Care plans for several residents specified that staff were to use gown and gloves for activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, device care, and wound care. Despite this, surveyors observed multiple instances where staff did not wear the required PPE while providing care or handling equipment in rooms of residents on EBP. Resident #1, who was cognitively intact and admitted with conditions including a periprosthetic fracture and presence of a left artificial hip joint, had a care plan intervention directing staff to use gown and gloves for high-contact activities. On one observation, a therapist transported this resident to therapy while in the resident’s room without any PPE, even as other staff in the room, including the Unit Manager and a CNA, were wearing yellow gowns. Resident #7, also cognitively intact and admitted with right hip bursitis and osteoarthritis, had a care plan intervention stating that PPE should be changed before caring for another resident. A lab technician was observed in this resident’s room finishing lab work without any PPE. Resident #9, with moderately impaired cognition and diagnoses including nutritional anemia, Alzheimer’s disease, and rheumatoid arthritis, had a care plan requiring gown and gloves for high-contact activities. A staff member in scrubs was observed exiting this resident’s room with a Hoyer lift and later using the Hoyer lift for the resident while wearing only gloves and no gown. Resident #10, cognitively intact and admitted with acute cystitis with hematuria, malignant neoplasm of the prostate, and peripheral vascular disease, also had a care plan requiring gown and gloves for high-contact activities. Another staff member was observed providing care to this resident in bed while wearing gloves but no gown. Interviews with a CNA, an LPN, and the DON confirmed that residents on EBP have signs outside their doors and that staff were expected to wear appropriate PPE, including gown and gloves, when entering rooms or providing direct care, which was inconsistent with the observed practices.
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