Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were properly implemented for a resident with a stage 2 pressure ulcer. The resident, who had severe cognitive impairment and an unhealed pressure ulcer on the right buttocks, was observed receiving wound care from a treatment nurse who did not wear a gown as required by EBP protocols. The nurse stated that gowns were only used if the wound had drainage, and did not use one for this resident's wound care. Further interviews with the Infection Preventionist revealed that the facility's practice was to place residents on EBP only for chronic wounds or wounds with copious drainage, and not for small or dry wounds, even if they were stage 2 pressure ulcers. The facility's policy indicated that EBP involves targeted gown and glove use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms, but this was not followed in the case of the resident with the stage 2 pressure ulcer.