Failure to Follow Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to follow its own infection prevention and control policy regarding enhanced barrier precautions for a resident with a pressure ulcer. Resident 19, who had diagnoses including dementia, seizures, and was receiving palliative and hospice care, was identified as having an unstageable pressure ulcer and was ordered to be on enhanced barrier precautions. Observations revealed that staff providing incontinence care and wound care to Resident 19 wore only gloves, without the required gowns, during high-contact care activities. Interviews with the CNA and LPN involved in the care indicated a lack of awareness or adherence to the enhanced barrier precautions policy, despite the presence of signage indicating such precautions were necessary. The facility's policy specified that both gloves and gowns should be used during high-contact activities such as changing briefs and wound care for residents with chronic wounds. The failure to use appropriate personal protective equipment during these activities constituted a breach of the facility's infection control protocols.