Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with a wound, as required by their infection prevention and control program. The resident, who was admitted with diagnoses including heart disease, atrial fibrillation, a personal history of urinary tract infections, and Alzheimer's disease, had a foam dressing on the sacrum that was not fully intact. During an observation, two CNAs were seen providing peri care to the resident without wearing gowns, and there was no isolation or enhanced barrier precaution sign on the resident's door. The resident's care plan indicated the need for enhanced barrier precautions due to the wound, specifying that staff should wear gowns and gloves during high-contact care activities. The Director of Nursing confirmed that the resident should have been on enhanced barrier precautions due to a pressure injury on the coccyx. The facility's policy for preventing the spread of multidrug-resistant organisms also highlighted the necessity of using gowns and gloves for residents with wounds or indwelling medical devices, regardless of colonization status. However, these precautions were not followed, leading to the deficiency.