Failure to Implement Enhanced Barrier Precautions and Proper Glove Use During Resident Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) and proper glove-changing protocols during care for a resident with a left heel wound exhibiting serous drainage. Observations revealed that there was no EBP signage or personal protective equipment (PPE) available outside or inside the resident's room. During wound care, a licensed nurse did not use EBP, and a certified nurse aide provided perineal care without changing gloves between dirty and clean tasks, contrary to facility policy. The administrative nurse confirmed that the resident should have been placed on EBP once the wound became open and draining, but this was not done. The facility's policies required EBP for residents with open wounds and specified glove changes between dirty and clean procedures during perineal care. However, staff did not follow these protocols, as evidenced by the lack of EBP implementation and improper glove use during care activities. These actions resulted in a failure to maintain a sanitary environment and to prevent the potential transmission of communicable diseases and infections among residents.