Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with open wounds, as required by facility policy and infection control standards. During a wound treatment observation, a CNA and an LPN provided care to a resident with sacral and right heel wounds, both wearing gloves but not gowns, and there was no EBP signage at the resident's doorway or in the room. The LPN cleansed and dressed the wounds without donning a gown, and the CNA assisted without a gown as well. Both staff members indicated in interviews that they did not believe EBP was necessary in the absence of wound drainage or isolation status, despite the resident having open wounds. The resident in question had diagnoses including dementia, hypertension, and diabetes, and had physician orders for wound care treatments. The care plan identified a risk for skin integrity impairment and included wound care interventions. Interviews with the Unit Manager RN and the Infection Preventionist confirmed that EBP should have been implemented for any resident with a wound, regardless of drainage. Facility policy also specified that gown and gloves are required for high-contact care activities involving residents with wounds, to prevent the transfer of multi-drug-resistant organisms (MDROs).