Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) in accordance with CDC guidelines for residents with wounds and indwelling medical devices. For one resident with an indwelling catheter and chronic wounds, staff did not consistently wear gowns during high-contact care activities such as catheter care and wound dressing changes. Observations showed that a nursing assistant performed catheter and wound care without a gown, despite facility protocols and signage indicating EBP requirements. The resident confirmed that staff did not always wear gowns during these procedures and expressed the importance of this practice to prevent infection spread. Another resident with a history of chronic skin issues and newly developed open wounds on the lower legs did not have EBP signage or PPE available in the room during wound care. Both an LPN and a nursing assistant performed dressing changes on open, draining wounds without wearing gowns, only using gloves. The staff involved acknowledged after the fact that they should have used gowns but proceeded with the care without them. The lack of EBP was only addressed after the wound care was completed and the open wounds were reported to the registered nurse, who then initiated the appropriate precautions. Facility policy required EBP for residents with indwelling medical devices or wounds, with clear instructions for staff to use gowns and gloves during high-contact care activities. However, documentation and interviews revealed that staff were not always aware of the need for EBP, particularly when new wounds developed or when returning from time off. The failure to consistently implement EBP as outlined in facility policy and CDC guidelines led to lapses in infection prevention during care for residents at high risk of infection.