Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Residents with Wounds
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions (EBP) and hand hygiene protocols for residents with wounds. For one resident with a history of MRSA in a right foot wound, staff did not consistently wear gowns and gloves during high-contact care activities such as peri-care, transferring, and toileting, despite signage indicating the need for these precautions. Observations revealed that staff wore only gloves, omitted gowns, and did not perform hand hygiene between glove changes while providing care. Interviews with staff confirmed a lack of adherence to EBP and hand hygiene expectations during these activities. Additionally, the facility did not assign EBP to another resident with a stage two pressure ulcer on the left big toe. This resident's care plan and physician orders did not indicate the need for EBP, and there was no signage or PPE cart outside the room. Staff interviews revealed that EBP was not being used for this resident, and the care plan lacked documentation of an MDRO, which was cited as a criterion for EBP by the assistant director of nursing. However, the facility's own infection prevention program indicated that residents with wounds, such as pressure ulcers, should be identified for EBP. The facility's policies directed staff to use gowns and gloves during high-contact care for residents on EBP and to perform hand hygiene between glove changes. Despite these policies, observations and staff interviews demonstrated that these protocols were not consistently followed, resulting in deficiencies related to infection prevention and control for residents with wounds.