Failure to Follow Enhanced Barrier Precautions for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and services to promote healing and prevent infection for a resident with a pressure ulcer, as required by professional standards. The deficiency was identified during an observation of wound treatment for a resident diagnosed with dementia and hypertension, who had an unstageable pressure injury on the third toe of the right foot. The facility's policy on 'Enhanced Barrier Precautions' mandates the use of gowns, gloves, and masks during high-contact procedures such as wound treatment to prevent the transmission of multidrug-resistant organisms. During the wound treatment observation, an LPN entered the resident's room wearing a facemask and performed hand hygiene and glove changes but did not wear a gown, contrary to the facility's Enhanced Barrier Precautions policy. The resident was on droplet precautions for influenza, and the Enhanced Barrier Precaution sign was placed on the back of the resident's door. The Director of Nursing confirmed that the resident should have been under both droplet and Enhanced Barrier Precautions, and the LPN should have worn a gown during the procedure to comply with the facility's protocol.
Plan Of Correction
1. R2 no longer resides at the facility. The DON educated E3 immediately on Initiation of Enhanced Barrier Precautions to be obtained for residents with chronic wounds such as pressure ulcers consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This includes all residents under any type of precautions to ensure appropriate signage is posted to reflect as such. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and or IP Nurse and nursing staff by March 14, 2025 to identify residents under any type of precautions to ensure appropriate signage is posted prior to employees entering the room. 3. DON and IP Nurse will educate all staff by March 14, 2025 addressing observance of signs posted on the door to determine PPE precautions and the use of gloves, mask, gown when performing high contact procedures and to ensure gowns and gloves available immediately near or outside of the resident's room. 4. Random Audits will be conducted by IP Nurse and or DON of at least five residents per week for 4 weeks then monthly for 2 months until 100% compliance is achieved or as otherwise determined by Risk Management Team/Quality Assurance Committee to ensure compliance is obtained and maintained.