Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with a Stage III pressure ulcer on the mid back. The resident, who had a history of right shoulder fracture, dementia, and depression, required assistance with activities of daily living and had impaired cognition. Physician orders and care plans specified the use of EBP, including donning gown and gloves during high-contact care activities such as wound care, and indicated the need for EBP every shift due to the wound. During an observed dressing change, two LPNs entered the resident's room, washed their hands, and donned gloves, but did not don the required PPE (gown and gloves) prior to entering the room as per EBP protocol. Additionally, there was no PPE cart, no notification sign indicating EBP precautions, and no soiled linen bins available in or outside the room. Staff confirmed the absence of these required items and acknowledged the resident was on EBP for the wound, as per facility policy and physician orders.