Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy during wound care for a resident with a venous stasis ulcer. The resident, who had diagnoses including peripheral vascular disease and type 2 diabetes mellitus, had a physician's order for EBP and specific wound care instructions. During an observation of wound care, the resident was found sitting in a recliner with her legs elevated, and her right leg, which had an open wound, was resting directly on a visibly soiled chair covering without a protective barrier. The wound was exposed and had a small amount of serosanguineous fluid present. Staff interviews confirmed that a protective barrier should have been placed under the resident's leg to prevent the wound from contacting the soiled surface. Both the treatment nurse and the DON acknowledged that the wound should not have been exposed to the soiled chair covering, indicating a failure to follow the facility's EBP policy and procedures during wound care for this resident.