Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices as outlined in their own policies and procedures for a resident requiring Enhanced Barrier Precautions (EBP) during wound care. During an observed wound care treatment, an LVN and a CNA did not don gowns as required, despite an EBP sign posted outside the resident's room and a physician's order specifying the use of gown and gloves for direct care. The LVN prepared wound care supplies and the CNA assisted in turning the resident, both wearing gloves but not gowns. The LVN proceeded with the wound care treatment without a gown, stating that a gown was not necessary if the wound was not draining. However, the facility's policy and the EBP sign indicated that gowns and gloves were required for high-contact care activities, including wound care, regardless of wound drainage status. The resident involved was non-verbal, lacked decision-making capacity, and had a chronic wound in the sacrococcyx area. Medical records confirmed the need for EBP, and staff interviews later acknowledged that proper PPE, including gowns, should have been used during the wound care procedure. The Infection Preventionist and Director of Nursing both confirmed that the observed practice did not align with facility policy and recognized the potential for infection transmission when proper PPE is not utilized.