Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required, specifically by not ensuring that enhanced barrier precautions (EBP) were followed during wound care for a resident. During an observed wound care procedure, two registered nurses entered the resident's room, washed their hands, and donned gloves, but did not put on gowns as required by EBP protocols. An EBP sign was posted on the resident's door, and the resident had two wounds requiring dressing changes, which is an activity that mandates both gown and glove use according to CDC guidelines. Interviews with the nursing staff revealed gaps in EBP training and inconsistent understanding of when to use gowns and gloves. One nurse stated that EBP was only used for tasks with a risk of getting wet, and both nurses indicated that not all staff had received education on the new EBP signage or protocols. The DON confirmed that while some education and PPE supplies had been provided, not all staff had been trained, and additional educational materials had not yet been distributed. These actions and omissions led to the failure to implement EBP during high-contact resident care activities, as required.