Failure to Maintain Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain enhanced barrier precautions during wound care for Resident R271, who had a sacral wound. The facility's policy on 'Transmission Based Precautions' required the use of gowns and gloves for high-contact care activities, such as wound care, to reduce the transmission of multidrug-resistant organisms. However, during an observation, it was noted that a nurse aide and a licensed nurse provided wound care to Resident R271 while wearing only gloves, despite a sign on the resident's door instructing staff to wear both gowns and gloves. The licensed nurse, identified as an agency nurse, revealed that there were no gowns readily available and admitted to not having received training on enhanced barrier precautions. This lack of adherence to the facility's infection control policy was observed during the provision of continence and wound care, which are considered high-contact activities requiring enhanced barrier precautions. The deficiency was identified through observations, review of facility policies, clinical record reviews, and staff interviews.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. E11 and E10 were educated on Enhanced Barrier Precautions and location of PPE. The DON/designee educated staff on Enhanced Barrier Precautions and location of PPE. The DON/designee will do random observations of 5 staff members entering rooms requiring EBP to ensure appropriate PPE is worn. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.