Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care procedure for a resident with quadriplegia, diabetes mellitus, neurogenic bladder, and peripheral vascular disease, staff failed to follow appropriate infection control practices. The resident had an unstageable right hip pressure ulcer and an indwelling urinary catheter, with physician orders for daily wound treatments and enhanced barrier precautions (EBP), which require the use of gown and gloves during high-contact care. Observation revealed that both the LPN and the Assistant Director of Nursing entered the resident's room without donning gowns, despite EBP signage and supplies being available. The LPN performed the wound care using improper technique, including using the same gauze to clean multiple areas of the wound, handling bandage scissors without cleaning them between uses, and placing potentially contaminated scissors back with clean supplies. Additionally, when a dressing fell onto the bed, it was discarded, but the scissors were again used without cleaning before cutting a new dressing. Interviews with both the LPN and the ADON confirmed that the wound care was not completed as ordered and that EBP protocols were not followed. Policy reviews indicated that the facility's procedures required the use of gloves and gowns for such care, as well as proper hand hygiene and equipment cleaning. The failure to implement these infection control measures was observed directly and verified by staff, constituting a deficiency in the facility's infection prevention and control program.