Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement its infection control policy for Enhanced Barrier Precautions (EBP) during wound care for a resident with chronic wounds. During an observed wound care procedure, the Wound Nurse did not don a gown as required by the facility's EBP policy, despite signage and available personal protective equipment indicating the need for both gloves and a gown for high-contact care activities. The nurse performed hand hygiene and donned gloves but omitted the gown, then proceeded with wound care on multiple sites. Additionally, the Wound Nurse did not consistently change gloves or perform hand hygiene between wound sites, contrary to the facility's infection prevention and control policy. Specifically, after cleaning one wound, the nurse removed only one glove, performed hand hygiene on one hand, and then continued care on another wound without changing both gloves or performing full hand hygiene. The nurse also reapplied gloves without hand hygiene at certain points during the procedure. The nurse later acknowledged awareness of the EBP requirements and attributed the lapses to nervousness. The Director of Nursing confirmed that EBP and hand hygiene protocols were expected to be followed for residents with chronic wounds.