Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer located on the right fourth finger. The resident's care plan, revised to reflect the presence of the pressure area, did not include directives for EBP. During wound care observation, there was no signage indicating EBP in the resident's room, and the LPN performing wound care did not wear a gown as required by EBP protocols. Interviews with staff revealed inconsistent understanding and application of EBP, with some staff unaware that wounds required EBP and others acknowledging that wounds, catheters, and MDROs should be included. The DON confirmed that the resident should have been under EBP but was not. Review of facility policies showed that the infection control program did not mention EBP utilization, and the EBP policy itself specified that EBP should be used for residents with wounds during high-contact care activities, such as wound care, with gown and gloves required. The CDC guidance referenced also directs EBP implementation for residents with wounds or indwelling devices during high-contact care, regardless of MDRO status.