Failure to Implement Enhanced Barrier Precautions for Resident with New Pressure Ulcer
Penalty
Summary
The facility failed to implement infection control practices related to Enhanced Barrier Precautions (EBP) for a resident with a newly identified pressure ulcer. Upon observation, there was no signage or PPE cart outside the resident's room to indicate EBP was in place, despite other rooms in the hallway having appropriate signage. The resident, who had multiple diagnoses including palliative care, chronic respiratory failure, and diabetes, was found to have a new pressure ulcer on the left gluteus, with wound care orders initiated by the wound care nurse. However, there was no physician order for EBP, nor was EBP implemented at the time the wound was identified. Interviews with staff revealed that the wound care nurse believed EBP was in place, but acknowledged the lack of signage, PPE cart, and physician order when questioned. The Infection Preventionist/ADON stated they were not informed of the new wound and that the process for implementing EBP typically involved the nurse who discovered the wound. The facility's policy required EBP, signage, and PPE availability for residents with wounds, but these measures were not followed for this resident.