Failure to Implement Enhanced Barrier Precautions for Resident with Wound and Medical Devices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not applying Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors, including an open wound, colostomy, and an interventional radiology (IR) drain. Observations revealed that the resident did not have an EBP sign on or near the door, and staff, including a unit manager, assessed the resident's wounds and manipulated the IR drain while wearing gloves but not gowns, as required by EBP protocols. The care plan for the resident did not include interventions for EBP, and there was no physician's order for EBP in the resident's medical record. The resident had a history of necrotizing fasciitis, septicemia, and diabetes mellitus, and was cognitively intact at the time of the deficiency. Physician's orders included wound care, colostomy care, and management of the IR drain, but did not address EBP. The Infection Preventionist confirmed that the resident should have been on EBP, with appropriate signage, care plan interventions, and staff use of gowns during high-contact care activities, but acknowledged these measures were not in place.