Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions during wound care for a resident with multiple complex medical conditions, including cerebral infarction, heart failure, end stage renal disease, type two diabetes, and severe vascular dementia. The resident required extensive assistance with activities of daily living and had several wounds requiring dressings, as documented in the care plan and active physician orders. The care plan specifically included enhanced barrier precautions as an intervention for skin impairment. Signage outside the resident's room indicated that enhanced barrier precautions were required, including the use of gloves and gowns for high-contact care activities such as wound care. During an observed wound care session, an LPN, a CNA, and a wound physician entered the resident's room and performed wound care activities, including removing and applying dressings, without donning gowns as required by the enhanced barrier precautions protocol. All three staff members later confirmed in interviews that they did not wear gowns and acknowledged that the resident was supposed to be under enhanced barrier precautions. The Director of Nursing also confirmed the lack of appropriate personal protective equipment storage outside the resident's room at the time of the incident.