Failure to Implement Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with wounds on the right foot, as required by the facility's infection control policy. The resident, who had diagnoses including diabetes mellitus and atherosclerotic heart disease, was identified as having necrotic areas and an infection on the right foot. Despite the presence of wounds and a superimposed infection, EBP was not initiated until 31 days after the wounds were first identified. During this period, there was no EBP signage posted outside the resident's room, and personal protective equipment (PPE) such as gowns and gloves was not readily available for staff use. Observations by the surveyor revealed that a CNA provided high-contact care to the resident without wearing the required PPE. Interviews with nursing staff, the Infection Preventionist, and the Director of Nursing confirmed that EBP should have been implemented when the wounds were first identified, but none could explain the delay. The medical record review also failed to show any documentation of EBP being put into place at the appropriate time, indicating a lapse in adherence to infection control standards.