Failure to Use Enhanced Barrier Precautions and PPE During High-Contact Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not following its Enhanced Barrier Precautions (EBP) policy for a resident requiring high-contact care. The EBP policy, last reviewed January 25, 2026, required the use of PPE, including gowns and gloves, for high-risk residents with wounds or indwelling devices during high-contact care activities such as wound care, care of feeding tubes, hygiene, and changing briefs and linens. Clinical record review showed that Resident 1 had Steele-Richardson-Olszewski syndrome, dementia, an enteral feeding tube, and multiple stage four pressure ulcers on the sacrum, right hip, and buttocks, and was dependent on staff for toileting and personal hygiene. On February 25, 2026, at 12:00 p.m., a nurse aide was observed entering the resident’s room to change briefs without wearing a protective gown and stated she provided incontinence care without a gown. On February 27, 2026, at 1:00 p.m., the Director of Nursing confirmed that staff did not use appropriate PPE during this resident’s care, resulting in noncompliance with the facility’s EBP policy and state regulations at 28 Pa. Code 211.10(d) and 211.12(d)(1)(5).
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