Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control measures for two of four sampled residents by not ensuring that staff wore appropriate personal protective equipment (PPE) and that required signage was posted. Specifically, a Licensed Vocational Nurse (LVN) and a Restorative Nursing Assistant (RNA) entered the room of a resident on Enhanced Barrier Precautions (EBP) without donning isolation gowns and proceeded to perform a wound dressing change. The resident had a stage 4 pressure ulcer, quadriplegia, and moderate cognitive impairment, and was dependent on staff for activities of daily living. Physician orders indicated the resident was to be on EBP due to open wounds, and the facility's policy required gown and glove use during high-contact care activities such as wound care. A similar failure was observed with another resident, where no EBP signage or isolation cart was present at the room entrance, and the same staff did not wear isolation gowns while performing a wound dressing change. This resident had osteomyelitis, hemiplegia, hemiparesis, diabetes mellitus, and severe cognitive impairment, and was also dependent on staff for daily care. Physician orders required daily wound care for a diabetic ulcer. Both staff members acknowledged during interviews that they forgot to use gowns and were aware of the need to wear PPE for residents on EBP. The Director of Nursing confirmed that EBP precautions, including gown use, should be followed for residents with wounds.