Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions during a dressing change for a resident with pressure ulcers. During a continuous observation, an LPN performed hand hygiene, donned gloves and a gown, and completed a dressing change to the resident's sacrum. Near the end of the procedure, a CNA entered the room to assist but did not perform hand hygiene upon entry, donned gloves without a gown, and removed the dressing from the resident's left heel. The CNA continued to hold the resident's leg and did not perform hand hygiene or change gloves after removing the dressing. The LPN later confirmed that the CNA should have performed hand hygiene before donning gloves, worn a gown, and not removed the dressing from the resident's heel. The resident involved had a diagnosis of a stage four pressure ulcer of the sacral region and required enhanced barrier precautions for wound care, as indicated by physician orders. Facility policy required the use of gowns and gloves, as well as hand hygiene, during high-contact care activities such as wound care for residents with wounds. The Nurse Consultant confirmed that the facility's current policies required these precautions but stated there was no specific policy for dressing changes.