Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Chronic Wounds
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for two residents with chronic wounds. In one instance, a CNA provided morning care to a resident on EBP, including changing an incontinent brief, transferring the resident, and changing bed linens, while only wearing gloves and not a gown as required. The CNA acknowledged awareness of the EBP protocol and the need to wear both gown and gloves to prevent cross-contamination. The resident's care plan documented the need for EBP due to infection prevention standards. In another case, a resident with a surgical wound requiring daily dressing changes and recent antibiotic treatment did not have the required EBP signage or orange dot indicator outside the room. The DON confirmed the resident was on EBP and that the sign may have been removed during a room change or cleaning. Both the DON and Infection Control Nurse stated that staff should wear gloves and gowns when providing care to residents on EBP, and facility policy specifies the use of gown and gloves for high-contact care activities for residents at high risk of MDRO transmission.