Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a stage II, open moisture-associated pressure wound on the coccyx and a leaking catheter. During an observation, two CNAs and the DON provided wound care and repositioned the resident without donning gowns, despite EBP signage being present on the resident's door and PPE being available at the nurse's station. The DON and CNAs acknowledged that they should have worn gowns and gloves during the high-contact activity, and confirmed that their gloves came into contact with saturated padding under the resident. The resident involved had diagnoses including cerebral palsy, seizure disorder, depression, memory problems, and moderately impaired cognitive decision-making. The resident had a catheter in place and an unhealed pressure ulcer requiring a pressure-reducing device. Facility policy and in-service documentation indicated that EBP requires gowns and gloves during high-contact care such as wound care and changing briefs, but this protocol was not followed during the observed incident.