Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open left thigh wound requiring daily dressing changes. The Treatment Nurse (TN) did not wear a gown while preparing to perform the dressing change and was unaware that EBP was required for the resident, believing that the absence of an indwelling device meant EBP was unnecessary. There was also no EBP signage posted outside the resident's room to alert staff of the need for these precautions. The resident had a history of a left femur fracture, multiple pelvic fractures, and muscle weakness, and was admitted and readmitted to the facility with these diagnoses. Physician orders indicated daily wound care for a ruptured blood blister on the left medial thigh extending to the knee, including cleansing, application of Santyl ointment, and covering with gauze. Observations confirmed that the TN did not don a gown before starting the dressing change, and the lack of signage meant other staff were not alerted to the need for EBP. Interviews with the TN, Infection Preventionist (IP) Nurse, and Director of Nursing (DON) revealed a lack of understanding and oversight regarding the implementation of EBP for residents with open wounds. The facility's policy required EBP for residents with wounds, but both the IP and DON were unaware that the resident's wound was still open and being treated, resulting in the failure to implement appropriate precautions and signage.