Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy by not wearing appropriate PPE during wound care for a resident on EBP. The resident had been admitted on 03/23/18 with diagnoses including diabetes mellitus, acute hematogenous osteomyelitis, COPD, and a need for assistance with personal care. A significant change MDS dated 01/24/26 documented that the resident was cognitively impaired and had unhealed pressure ulcers. On 03/02/26 at 10:01 A.M., surveyors observed EBP signage on the resident’s door indicating that all staff and providers must wear a gown and gloves for high-contact resident care activities, including wound care and catheter care, and a PPE cart was available outside the room. The resident was observed to have a suprapubic catheter and a wound. Despite the posted EBP requirements, at approximately 10:01 A.M. LPN #440 entered the room, washed her hands, donned only clean gloves, and proceeded to position the resident and remove the old sacral wound dressing, discarding it in the garbage. LPN #440 then cleaned her hands and continued to cleanse the sacral wound without donning a gown. At 10:13 A.M., CNA #410 entered the room, donned clean gloves only, and assisted the LPN with positioning the resident by holding him on his side to allow better access to the wound, again without wearing a gown. In a follow-up interview at 10:32 A.M., LPN #440 confirmed that the resident was on EBP for both wounds and a urinary catheter and acknowledged that neither she nor the CNA had donned the appropriate PPE while providing wound care. Review of the facility’s EBP policy, revised 09/25, showed that residents with chronic wounds such as pressure ulcers and indwelling devices such as urinary catheters require EBP, and that high-contact resident care activities, including wound care and device care, require use of gown and gloves.
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