Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement and maintain Enhanced Barrier Precautions (EBP) for residents with active wounds, as required by their own infection prevention and control policy. Specifically, three out of four sampled residents with wounds or indwelling medical devices did not have EBP orders in place. For one resident with a stage 2 pressure ulcer and on dialysis, there were no EBP orders, no signage, and no personal protective equipment (PPE) observed in or outside the room, and the resident reported that staff did not wear gowns during direct care. Another resident with multiple unhealed pressure ulcers and a suprapubic catheter also lacked EBP orders, and although signage and PPE were present, the resident stated that staff did not wear gowns during care. A third resident with unhealed pressure ulcers similarly had no EBP orders, though signage and PPE were observed in the room. Record reviews and interviews confirmed that the facility's policy required EBP for residents with wounds or indwelling devices, including clear signage and availability of PPE. The Infection Preventionist acknowledged during interview and record review that all three residents should have had EBP orders in place, and could not provide additional information to explain the lack of compliance. The care plans for these residents referenced following facility protocols for skin breakdown prevention and, in one case, noted the need for EBP, but the required orders and consistent implementation were not present.