Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Nurse Aide #1 and Nurse Aide #2 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy when providing incontinence care to Resident #14, who had a chronic sacral pressure ulcer. Both nurse aides performed hand hygiene and donned gloves but did not wear gowns, as required by the EBP policy for residents with wounds during high-contact care activities such as changing briefs. The aides believed that because there was no EBP signage or PPE on the door and the wound appeared to be covered with a preventative dressing, enhanced precautions were not necessary. Observation revealed that Resident #14 had a clean, dry border foam dressing on the sacrum, and the Infection Preventionist confirmed the presence of a chronic pressure ulcer with a small opening and no drainage. The Infection Preventionist stated she did not believe EBP was needed due to the wound's size and lack of drainage. However, the Director of Nursing later clarified that EBP should have been implemented for the resident due to the chronic wound, and appropriate signage and PPE should have been in place to alert staff.