Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer. According to the facility's policy, EBP, including the use of gowns and gloves, should be used during high-contact care activities for residents with chronic wounds, such as pressure ulcers. During an observation, a Treatment Nurse and a Nurse Aide provided wound care to a resident with an unstageable pressure ulcer without donning gowns, and there was no signage or PPE supplies outside the resident's room to indicate EBP was required. The staff performed hand hygiene and changed gloves multiple times during the procedure but did not use gowns as required by policy. Interviews with the involved staff revealed that the Treatment Nurse did not believe EBP was necessary due to the absence of significant wound drainage, and the Nurse Aide assumed EBP was not needed because there was no signage. The Infection Preventionist acknowledged that the resident should have been placed on EBP when the pressure ulcer was identified, attributing the failure to a miscommunication with the Treatment Nurse. The Director of Nursing also confirmed that EBP should have been implemented when the pressure ulcer was first identified, but it was delayed due to uncertainty about the wound's status and a lapse in communication.