Failure to Use Required PPE Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy and posted instructions for use of personal protective equipment (PPE) during high-contact care activities for residents on EBP. The facility’s undated EBP policy required staff to wear gowns and gloves for high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care such as urinary catheter care. For one resident on EBP with a urinary catheter, a nurse entered the room where an EBP sign was posted on the door and PPE was available behind the door. The sign indicated that both gloves and a gown were required for high-contact care such as urinary catheter care. The nurse performed urinary catheter care wearing only gloves, without donning a gown, then discarded supplies and gloves and performed hand hygiene. In a subsequent interview, the nurse acknowledged awareness that the resident was on EBP but stated she did not know a gown was required for urinary catheter care. A second deficiency occurred when a nurse aide provided high-contact care to another resident on EBP without using all required PPE. This resident’s room also had an EBP sign posted outside the door instructing staff to wear a gown and gloves for high-contact activities such as transfers and urinary catheter care, and PPE was available on the back of the door. The nurse aide applied hand sanitizer and donned gloves but did not put on a gown before assisting the resident with a stand-pivot transfer from wheelchair to bed and handling the resident’s urinary catheter bag, including moving the bag and emptying it into a urinal, then disposing of the urine and cleaning the urinal. In an interview, the nurse aide stated she was not aware the resident was on EBP, reported she did not notice the dark gray EBP sign because she was used to light blue signs with red stop signs, and stated she did not know a gown was required for transferring and providing care to residents with urinary catheters. The DON/Interim Infection Preventionist and the Administrator both stated that staff were expected to use PPE according to the EBP signs posted for each resident.
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