Failure to Implement Enhanced Barrier Precautions for Resident with Skin Impairment
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident who had an actual area of skin impairment, specifically a suspected deep tissue injury (SDTI) on the bilateral buttocks. The resident's medical record indicated multiple diagnoses, including acute embolism, thrombosis, muscle weakness, and Type II Diabetes Mellitus, and the resident was assessed as cognitively intact. Despite the facility's policy requiring an order for enhanced barrier precautions for residents with wounds, there was no such order in the physician's orders, and the resident's care plan did not include interventions for enhanced barrier precautions. During observation, there was no signage or enhanced barrier precautions cart with gowns and gloves outside the resident's room, and no trash can was positioned inside the room near the exit for discarding personal protective equipment, as required by facility policy. The Assistant Director of Nursing confirmed that the resident should have been on enhanced barrier precautions but was not. This deficiency affected one resident and had the potential to impact all residents on the hall.