Failure to Implement Enhanced Barrier Precautions for Wound Care
Penalty
Summary
The facility failed to maintain effective infection control practices related to enhanced barrier precautions for a resident with a stage four pressure ulcer. The facility's policy on Enhanced Barrier Precautions, dated March 2024, requires the use of gowns and gloves during high-contact care activities, such as wound care, to prevent the transmission of multi-drug resistant organisms. However, during an observation on January 12, 2025, it was noted that two employees, a licensed nurse and a nurse aide, provided wound care to the resident's sacral wound while only wearing gloves, neglecting to wear gowns as required by the policy. The resident in question was admitted to the facility in September 2023 and had a diagnosis of a stage four pressure ulcer in the sacral region, which is the most severe stage of a pressure sore and has a high risk of infection. The resident's care plan, dated April 29, 2024, specified the need for enhanced barrier precautions, including the use of gloves and gowns during wound care. Despite this, the employees did not adhere to the required precautions, as confirmed by the licensed nurse during an interview following the observation.
Plan Of Correction
Employee E8 and E9 were rein-serviced on maintaining effective infection control practices related to enhanced barrier precautions. A house-wide audit was completed of residents with enhanced barrier precautions to ensure that staff were maintaining effective infection control practices related to enhanced barrier precautions. Staff members will be in-serviced to ensure that the facility maintains effective infection control practices related to enhanced barrier precautions. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that staff are maintaining effective control practices related to enhanced barrier precautions. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.