Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Medical Devices
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for two residents with wounds and/or indwelling medical devices, as required by facility policy and physician orders. For one male resident with a cholecystectomy drain, pressure ulcer on the right heel, and a deep tissue injury to the left medial bunion, staff did not post EBP signage outside the room, nor did they wear gowns during high-contact care activities such as transferring, bed making, and adjusting the resident. Although gloves were used for some tasks, gowns were not worn, and staff were observed handling the resident and his belongings without full PPE as required. Interviews revealed that staff believed gowns were only necessary when wounds were exposed, contrary to the facility's EBP policy, which mandates gown and glove use for all high-contact care activities for residents under EBP. For another resident with an unstageable pressure ulcer on the right heel and a dialysis access site, EBP orders were in place, but there was no signage or PPE cart outside the room, and staff did not use PPE during care activities. Nursing staff documented that EBP was in place and completed each shift, but observations and interviews confirmed that EBP was not actually implemented until several days after the order was written. Staff, including an LPN and CNAs, provided care such as medication administration, wound dressing changes, and transfers without wearing gowns or gloves as required. Interviews with nursing staff, the infection preventionist, and the nursing supervisor confirmed a breakdown in communication regarding the initiation and implementation of EBP. Staff were unaware of the EBP orders or did not follow them, and documentation inaccurately reflected that precautions were in place when they were not. The failure to implement EBP as ordered and per facility policy resulted in a deficiency related to infection prevention and control.