Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents identified as requiring them, as observed and confirmed by staff and record review. For one resident with multiple diagnoses including intracranial hemorrhage, diabetes, and unhealed pressure ulcers, there was an EBP sign on the door but no personal protective equipment (PPE) cart available outside the room. During a wound dressing change, the DON wore gloves but did not don a gown, despite the presence of an open wound, and there was no physician order for EBP in the medical record. Staff were also confused about which resident required EBP in the shared room. For another resident with diagnoses including malignant neoplasms and a gastrostomy tube, there was no EBP sign or PPE cart outside the room, and no physician order for EBP was present. The DON confirmed that EBP was indicated due to the presence of a gastrostomy tube, as per facility policy, but these precautions were not implemented. Facility policy required EBP for residents with wounds or indwelling medical devices, but these procedures were not followed for the two affected residents.