Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident requiring enhanced barrier precautions due to a stage 4 sacral pressure ulcer and the presence of a catheter. During wound care, both the wound care nurse (WCN) and a certified nursing assistant (CNA) did not wear the required personal protective equipment (PPE), specifically gowns, despite clear physician orders and signage indicating the need for enhanced barrier precautions. Both staff members also failed to perform hand hygiene after removing gloves during the procedure, contrary to facility policy and established infection control protocols. The resident involved had significant medical conditions, including a stage 4 pressure ulcer, hypertension, and type 2 diabetes, and required daily wound care with specific instructions for PPE use. Interviews with the WCN and CNA revealed that both were aware of the correct procedures but forgot to follow them during the observed wound care. The Director of Nursing confirmed that the staff should have worn gowns and performed hand hygiene as required by the facility's infection control policy, which was last reviewed in a recent in-service.