Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when the facility failed to identify the need to place a resident with multiple open wounds on Enhanced Barrier Precautions (EBP), an infection control strategy designed to prevent the spread of multidrug-resistant organisms (MDROs). The resident, who was admitted with a complete traumatic amputation of the left midfoot, had an open wound on the left foot with moderate serosanguineous drainage and a sacral wound with light serosanguineous drainage. During observation, there was no personal protective equipment (PPE) or EBP signage posted outside the resident's room, despite the resident receiving wound care for both the left foot and buttocks. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the resident was not on EBP, even though facility policy required EBP for residents with wounds. The DON stated she was unaware that the resident was not on EBP and acknowledged that the resident should have been placed on these precautions due to the presence of wounds. Review of the facility's policy indicated that PPE should be available outside the resident's room and clear signage should be posted, neither of which was observed during the survey.