Failure to Implement Enhanced Barrier Precautions for Resident with Surgical Wound
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for a resident with a surgical wound. The resident, who had a history of cranioplasty and a slowly healing, dehisced surgical wound, was admitted and readmitted to the facility. Physician orders were in place for daily wound care, including cleansing and dressing changes for both the scalp and left temple wounds. However, there was no physician order for Enhanced Barrier Precautions (EBP), which are required for residents with wounds at high risk for colonization with multidrug-resistant organisms (MDROs). During observations, the resident was found in bed with wound dressings but without any PPE set-up or EBP signage outside the room. Interviews with the LVN and Infection Preventionist (IP) confirmed that EBP was not implemented, despite both acknowledging that EBP should have been in place due to the resident's surgical wound. The IP also verified the absence of a physician's order for EBP and the lack of necessary precautions. Further review and interviews with the Director of Nursing (DON) and the Administrator confirmed that the resident had a surgical wound and that EBP, including PPE set-up and signage, was not implemented as required. The facility's failure to follow its own infection prevention and control policies and procedures resulted in the deficiency, as the necessary precautions to prevent the transmission of communicable diseases or organisms were not in place for the resident.
Plan Of Correction
F0880 signage, orders and care plans were in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Infection Preventionist/Designee conducted an in-service from 8/5/25 - 8/12/25 to licensed nurses regarding EBP practices and the criteria that would require implementation. Infection Preventionist will make daily rounds and audit new admissions and current residents on EBP, Monday - Friday x 3 months to ensure proper implementation of EBP on the floor that includes signage, orders and care plans are in place. DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025 DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025