Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as part of its infection prevention and control program for residents with pressure ulcers. Specifically, during a wound care observation for a resident with an active wound and a history of pressure ulcers, staff did not adhere to EBP requirements by failing to wear protective gowns in addition to gloves. The medical record review for this resident did not show any physician order for EBP, nor was there documentation or care plan indication that EBP was being used or considered. Another resident requiring wound care also did not have documentation of EBP implementation or assessment in their record, and there was no signage at the resident's doorway indicating the need for EBP. The Director of Nursing confirmed that EBP should be implemented for residents with pressure ulcers and was made aware of the staff's failure to wear gowns during wound care and the lack of physician orders for EBP for both residents.