Failure to Implement Enhanced Barrier Precautions for Residents with Open Wounds
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) for two residents with open wounds who were receiving wound care. Multiple observations revealed that there was no EBP personal protective equipment (PPE) or signage set up in or around the rooms of these residents on several occasions. Staff members, including licensed nurses, reported that they only used gloves during dressing changes and did not utilize gowns, even when treating open wounds. Staff interviews indicated inconsistent understanding and application of EBP, with some staff believing that gowns were only necessary if there was a risk of exposure to bodily fluids or if the wounds were colonized with multi-drug-resistant organisms. One resident had wounds on the abdominal folds being treated with silver alginate and an ABD pad, while another had two open areas being debrided and treated with Silvadene. Despite the facility's Infection Management Process policy stating that PPE should be available and signage posted to direct staff and visitors, these measures were not observed in practice for the affected residents. Administrative staff provided varying explanations regarding when EBP PPE should be used, further highlighting the lack of consistent implementation of infection control protocols.