Failure to Follow Enhanced Precautions for Wound Care and COVID-19
Penalty
Summary
Staff failed to follow appropriate transmission-based precautions for two residents requiring enhanced infection control measures. One resident with moderate cognitive impairment, dementia, and frostbite with surgical amputations had provider orders and a care plan directing staff to use enhanced barrier precautions (EBP), including donning gown and gloves during high-contact care. During a dressing change, a registered nurse performed hand hygiene and wore gloves but did not don a gown, despite signage and policy requiring both. The nurse later acknowledged the omission. The Director of Nursing confirmed that EBP required gown and gloves for wound care, as outlined in facility policy. Another resident with a recent COVID-19 diagnosis was on enhanced respiratory precautions, with care plan interventions for isolation and monitoring but lacking specific PPE instructions. Observations showed that staff entered the resident's room wearing only surgical masks or omitting required PPE such as N95 respirators and eye protection, despite signage indicating enhanced respiratory precautions. Interviews with staff revealed inconsistent understanding and implementation of required PPE protocols for both EBP and enhanced respiratory precautions, as well as a need for further education on the differences between these precautions.