Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a resident with a stage four pressure ulcer, acquired while in the facility, was not placed under Enhanced Barrier Precautions (EBP) as required by facility policy. During a dressing change, an LPN was observed wearing only gloves and not a gown, which is mandated for wound care under EBP guidelines. Additionally, there was no personal protective equipment (PPE) available in or outside the resident's room for staff to access during care. Interviews with the LPN and the Director of Nursing confirmed that the resident should have been under EBP due to the open wound and that the appropriate PPE, including a gown, should have been used during the dressing change. The failure to follow EBP protocols was directly observed and acknowledged by staff, and the lack of accessible PPE further contributed to the deficiency.