Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During an observation of wound care for a resident with a pressure ulcer, both a nurse and a Wound Aide failed to follow the facility's infection control policy regarding Enhanced Barrier Precautions (EBP). The facility's policy, dated 9/22, requires the use of both gowns and gloves during high contact care activities, including wound care for residents identified as requiring EBP. However, during the dressing change, both staff members wore only gloves and did not don gowns before or during the procedure, despite the presence of personal protective equipment (PPE) in the room. Interviews following the incident revealed that the Wound Aide admitted to forgetting to wear a gown due to nervousness, while the nurse believed a gown was unnecessary since she was only assisting with positioning the resident. The Staff Development Coordinator (SDC), who was present to observe the dressing change, did not initially notice the lack of gowns until after the procedure had begun. Both the SDC and the Director of Nursing (DON) confirmed that the staff should have been wearing gowns during the dressing change, in accordance with facility policy.