Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program by not placing a resident with an open sacral wound and dressing on Enhanced Barrier Precautions (EBP) as required. The resident, who was admitted with multiple diagnoses including fractures, chronic kidney disease, diabetes, and edema, had a Stage III pressure sore to the sacrum documented on admission. Medical records showed that wound care orders were in place and treatments were administered as scheduled. However, during observation, there was no EBP signage on the resident's door, nor was there a bin with personal protective equipment (PPE) present, despite facility policy and training indicating these measures were necessary for residents with open wounds requiring dressings. Interviews with the treatment nurse revealed a lack of awareness that EBP was required for open wounds with dressings, and the DON was not aware that the resident was not on EBP. The facility's own policy and previous staff in-service training specified that EBP, including signage and PPE, should be implemented for wound care involving any skin opening requiring a dressing. Despite these protocols, the required precautions were not followed for this resident, as confirmed by both observation and staff interviews.