Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for two residents who required such measures due to their medical conditions. Both residents had significant wounds, including stage 3 and stage 4 pressure ulcers, and one had a diagnosis of Fournier gangrene. During wound care observations, signage and PPE supplies were present at the residents' doors, indicating the need for EBP. However, three staff members, including an RN and two LPNs, entered the rooms and performed high-contact wound care without donning gowns as required by the facility's policy and the residents' care plans. Interviews with the involved staff confirmed that gowns were not worn during the procedures, despite their awareness that EBP should be followed for wound care. The residents' care plans specifically documented the need for staff to don gowns and gloves before providing high-contact care activities, and the facility's policy outlined the use of PPE for residents with wounds or indwelling medical devices. The Acting Director of Nursing also confirmed that staff are expected to adhere to these protocols.