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F0880
F

Failure to Implement Enhanced Barrier Precautions for Residents with Chronic Wounds and Indwelling Devices

Windsor, North Carolina Survey Completed on 05-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. During an observation of wound care provided to a resident with chronic wounds, neither the nurse nor the nurse aide wore gowns as required for high contact care activities under EBP. Additionally, there was no signage indicating the need for EBP in the resident's room, and personal protective equipment (PPE) for EBP was not readily available. Interviews with staff revealed a lack of awareness and training regarding EBP. The wound care nurse and nurse aide both stated they had not received education on EBP and were unaware of which residents required these precautions. The Assistant Director of Nursing, who also served as the Infection Preventionist, admitted she had not implemented EBP in the facility and was unfamiliar with the requirements for residents with chronic wounds or indwelling devices. The Director of Nursing was aware of the EBP requirements but was unsure why they had not been implemented, and the Administrator could not explain the lack of EBP implementation or staff training. A review of the facility's resident list identified 41 residents with chronic wounds or indwelling medical devices who should have been on EBP but were not. The facility's policy required EBP for such residents, including the use of gowns and gloves during high contact care, appropriate signage, and staff notification, none of which were in place at the time of the survey.

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