Failure to Implement Timely Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate timely Enhanced Barrier Precautions (EBP) for a resident admitted with surgical wounds. The resident, who was in the facility for rehabilitation following hip repair surgery, had two dressings on the left lower extremity but did not have any signage indicating EBP. This oversight was identified during an observation and interview with the resident, who confirmed the absence of EBP measures. Interviews with the Assisted Director of Nursing/Infection Control Preventionist (ADON/ICP) and the Director of Nursing (DON) revealed that the facility's policy required EBP for residents with wounds, including surgical wounds. The ADON/ICP acknowledged that the resident should have been placed on EBP upon admission. The DON admitted awareness of the issue and attributed it to the high turnover of admissions and discharges, indicating a need for improvement in implementing EBP for residents with wounds.
Plan Of Correction
1. Resident #345's plan of care was updated to include enhanced barrier precautions. 2. Director of Nursing/Designee have completed a review of current facility residents to confirm enhanced barrier precautions are implemented if indicated. Follow up based on findings. 3. Staff Development Coordinator/Designee has conducted education with licensed nurses related to implementation of enhanced barrier precautions. 4. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of facility residents to verify enhanced barrier precautions are implemented if indicated daily x 4 weeks, weekly x 4 weeks, then monthly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Meeting. Modifications implemented as indicated.