Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for two residents who had pressure ulcers and were on EBP due to their wounds. For both residents, signage was posted on their doors instructing that all staff must clean their hands before entering and leaving the room, and that providers and staff must wear gloves and a gown during high-contact care activities such as wound care. Despite these instructions, a Licensed Practical Nurse (LPN) was observed entering the rooms of both residents to provide wound care while only donning gloves and not a gown. Both residents had significant medical histories, including chronic kidney disease, polyneuropathy, peripheral vascular disease, chronic obstructive pulmonary disease, and traumatic brain injury. Each had a documented pressure ulcer, with one resident having a stage 3 ulcer and the other an unstageable ulcer. The LPN acknowledged that both residents were on enhanced barrier precautions due to their wounds and confirmed that staff are required to don both gown and gloves before providing care. The Director of Nursing also confirmed that the LPN should have worn a gown in addition to gloves during the observed wound care activities.