Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified that the facility failed to implement enhanced barrier precautions for a resident with a Stage 3 pressure ulcer and a chronic vascular ulcer, both requiring physician-ordered dressing changes. Despite a facility policy requiring the use of gowns and gloves for high-contact care activities for residents with wounds, staff did not place the resident on enhanced barrier precautions, and there was no signage indicating such precautions on the resident's door. During wound care observations, both the Infection Preventionist and the LPN Unit Manager did not don gowns while performing dressing changes. The resident involved had diagnoses including diabetes, dementia, and a pressure ulcer to the left buttock, with documented moderate cognitive impairment and the need for assistance with most activities of daily living. The electronic medical record lacked a physician's order or care plan for enhanced barrier precautions. The Infection Preventionist acknowledged during an interview that the resident should have been on enhanced barrier precautions and that a gown should have been worn during dressing changes.