Failure to Implement and Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently donned appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) and did not maintain or follow EBP orders as required. In one instance, a resident with a left great toe amputation and a wound covered by a dressing was observed receiving wound care from an LPN who wore gloves but did not wear a gown, despite the EBP signage indicating that both gown and gloves were required for wound care and dressing changes. The LPN stated that a gown was not necessary because there was no anticipated contact with body fluids and the dressing change was performed in a way to avoid contact with clothing or the resident's body. In another case, a resident with a healing sacral wound and an active physician's order for EBP did not have the required EBP sign on the door or a PPE cart outside the room. This was confirmed during a tour of the nursing unit, and facility leadership acknowledged that residents with EBP orders should have both the sign and PPE cart in place. These deficiencies were identified through observation, record review, and staff interviews.