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F0945
E

Failure to Train Staff and Implement Enhanced Barrier Precautions for Residents with Chronic Wounds

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 implement an effective infection prevention and control training program for nurses and nurse aides, specifically regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The Assistant Director of Nursing (ADON), who was responsible for staff training on infection prevention, was unaware that EBP was required for residents with these conditions during high contact care. Additionally, the ADON had not initiated any training program for staff on infection control practices and procedures. This lack of training and awareness extended to the Director of Nursing (DON) and the facility Administrator, both of whom were unaware that staff had not been trained or deemed competent in EBP protocols. During observations, it was noted that a nurse and a nurse aide provided wound care to a resident with chronic wounds without wearing gowns, which was a direct violation of the facility's infection control policy. The facility had 41 residents who required EBP due to chronic wounds or indwelling medical devices, and the failure to follow proper precautions was identified in all three staff members reviewed for competency. These findings were based on staff interviews, record reviews, and direct observation.

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