Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed nurse performed wound care on a resident without adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. During the wound care procedure, the nurse donned gloves but failed to wear a gown as required for EBP. The nurse also did not consistently perform hand hygiene between glove changes, specifically after removing gloves and before donning new ones during the care of multiple wounds. The nurse transitioned between treating the resident's leg wound and coccyx wound without completing care on one wound before moving to the next, contrary to facility expectations and infection control best practices. Interviews with nursing staff and administrative nurses confirmed that the facility's policy required the use of both gown and gloves for wound care under EBP, completion of care on one wound before addressing another, and hand hygiene with every glove change. The facility's infection control policy also documented that all team members would be trained on these practices. The observed failure to follow these protocols during wound care placed the resident at risk for wound infection and related complications.