Failure to Use Required PPE Under Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring appropriate use of personal protective equipment (PPE) under Enhanced Barrier Precautions (EBP) during wound care. A cognitively intact resident with diagnoses including cerebral infarction, colostomy status, malignant melanoma of the right upper limb, an indwelling catheter, an ostomy, and open skin lesions had active physician orders for daily right upper arm wound care and for EBP. The EBP orders specified that staff must use gown and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs), and that EBP is indicated for residents with wounds and indwelling medical devices regardless of MDRO colonization. The facility’s EBP policy, revised in March 2024 and February 2025, required targeted gown and glove use for high-contact care activities, including wound care for any skin opening requiring a dressing. On the survey date, an LPN was observed performing right upper arm wound care on this resident without donning a gown, despite an EBP sign posted next to the resident’s door and the active EBP orders. The LPN conducted the wound care while only partially complying with the required PPE, as she did not wear a gown for this high-contact activity. In interviews, the DON stated her expectation that staff wear gloves and gowns when entering and performing care on residents under EBP, and the Administrator stated that door precaution signs inform staff of required PPE, including gowns and gloves, and that she expected staff to wear them. Both the DON and Administrator acknowledged that failure to wear the appropriate PPE, including a gown, placed the resident and staff at risk for infection, demonstrating that the observed practice did not conform to facility policy or provider orders for EBP.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.