Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions (EBP) during wound care for a resident with a diabetic foot ulcer and increased risk for colonization of multidrug resistant organisms (MDRO). The resident required substantial assistance with mobility and had multiple diagnoses, including diabetes, renal disease, and dementia. The care plan specifically directed staff to use EBP, and signage on the resident's door instructed staff to wear gloves and gowns during high-contact care activities such as wound care. During an observed dressing change, an LPN and a Certified Medication Aide assisted with the procedure but did not wear gowns as required by facility policy and posted instructions. The LPN acknowledged forgetting to don a gown despite having received education on the policy. The facility's policy, updated prior to the incident, clearly defined EBP and required the use of gowns and gloves during wound care for residents with wounds requiring dressings.