Failure to Apply Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were consistently applied during wound care for a resident with a Stage 4 pressure ulcer in the sacral area. The resident had a physician's order and a care plan in place requiring the use of EBP, including the use of personal protective equipment (PPE) during high-contact care activities such as wound care. Observations revealed that a sign and PPE storage were present outside the resident's room, indicating the requirement for PPE use. However, an LPN was observed entering the resident's room and performing wound care without donning the required PPE, despite the presence of red-colored drainage from the wound. Interviews with the LPN, the Assistant Director of Nursing, and the Infection Control Preventionist confirmed that PPE was expected to be worn during wound care and that staff had been in-serviced on these protocols. Record review of the facility's policy also documented the requirement for enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms. The failure to follow these established protocols and physician orders resulted in a deficiency related to infection prevention and control practices.