Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers, as required by facility policy and physician orders. The policy specifies that gloves and gowns must be worn during high-contact care activities for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms (MDROs). The resident in question had a stage three pressure injury on the left Achilles area and a stage four pressure injury on the left ischial area, and the care plan and physician orders both indicated that EBP should be maintained during high-contact care, including wound care and urinary catheter care. During an observation, a registered nurse and an LPN entered the resident's room and performed wound care without donning gowns, despite an EBP sign on the door instructing staff to wear gowns and gloves for such activities. Both staff members stated that they believed the EBP sign and supplies were intended for the resident's roommate, not for the resident receiving wound care. The Director of Nursing later confirmed that the resident was on EBP and that the staff should have worn gowns and gloves during the wound treatment.