Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a stage II, open moisture-associated pressure wound on the coccyx and a leaking catheter. During an observation, two CNAs and the DON provided wound care and repositioned the resident without donning gowns, despite EBP signage being present on the resident's door and PPE being available at the nurse's station. The DON and CNAs acknowledged that they should have worn gowns and gloves during the high-contact activity, and confirmed that their gloves came into contact with saturated padding under the resident. The resident involved had diagnoses including cerebral palsy, seizure disorder, depression, memory problems, and moderately impaired cognitive decision-making. The resident had a catheter in place and an unhealed pressure ulcer requiring a pressure-reducing device. Facility policy and in-service documentation specified that gowns and gloves must be worn during high-contact care such as wound care and changing briefs for residents on EBP. The DON, CNAs, Administrator, and Medical Director all confirmed the expectation that EBP should be followed to prevent infection transmission.