Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy during wound care procedures for two residents under Enhanced Barrier Precautions (EBP). The Wound Nurse did not don a gown as indicated by the EBP signage when performing wound care on a resident with a stage IV pressure ulcer and another resident with a lower right leg wound. In both cases, the signage clearly directed staff to wear gloves and a gown for high-contact resident care activities, including wound care, but the Wound Nurse only wore gloves. Additionally, during the wound care for the resident with the stage IV pressure ulcer, the Wound Nurse failed to perform hand hygiene after removing gloves and before donning new gloves, contrary to the facility's hand hygiene policy. Interviews with the Wound Nurse revealed a misunderstanding of the EBP requirements, as she believed gowns were only necessary if there was a risk of splash or if the wound was infected. The interim DON confirmed that the facility's policy required both gloves and gowns for all wound care under EBP and that hand hygiene should be performed after glove removal and before applying new gloves. These observations and staff interviews demonstrated noncompliance with the facility's infection control policies for both hand hygiene and the use of personal protective equipment during wound care.