Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) as ordered for a resident with a pressure ulcer. Specifically, observations on multiple dates revealed that there was no EBP signage posted in the resident's room, despite a physician's order for EBP and the facility's policy requiring the use of gown and gloves during high-contact care activities for residents with wounds or indwelling medical devices. The resident involved had an unstageable pressure ulcer of the left heel and was cognitively intact according to a recent assessment. The Director of Nursing confirmed that EBP signage should have been posted but was not present at the time of observation.