Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to follow infection prevention and control protocols during wound care for a resident with pressure ulcers. The LPN performed hand hygiene and donned gloves prior to starting, but did not wear a personal protective gown as required under Enhanced Barrier Precautions (EBP) for residents with wounds. During the procedure, the resident was found to be incontinent of bowel, and the LPN cleaned the area but did not perform hand hygiene or change gloves before proceeding with wound care on the resident's left lower back and sacrum. The LPN also touched personal items, wrote on wound dressings, applied a new brief, and repositioned the resident without changing gloves or performing hand hygiene between these activities. Facility policies required the use of gowns and gloves during high-contact care activities, such as wound care, under EBP, and specified hand hygiene before and after care, especially when hands become soiled. The resident involved had a history of pressure ulcers and protein-calorie malnutrition, with physician orders for specific wound care procedures. The LPN later acknowledged not being educated on EBP and was unaware of the need for a gown during wound care for residents with pressure ulcers. The Director of Nursing confirmed that EBP should have been followed and that the LPN's actions did not meet infection control standards.