Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its infection control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for residents who met the criteria for these precautions. Specifically, three out of six staff members observed and reviewed for infection control practices did not wear a gown while performing or assisting with wound care, as required by the facility's EBP policy. The policy mandates the use of gloves and gowns for high-contact resident care activities, including wound care for residents with open wounds or indwelling medical devices, even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). During wound care for a resident with a stage 2 pressure ulcer, a nurse was observed performing hand hygiene and using gloves but did not don a gown at any point during the procedure. The nurse later stated she believed a gown was unnecessary because the wound was not open, although she acknowledged the resident should have been on EBP. Another nurse who regularly performed wound care for the same resident was unaware that EBP was required for residents with open wounds and had not been informed by the Infection Preventionist. The Infection Preventionist was also unaware that the resident's pressure ulcer was open and confirmed that EBP should have been initiated when the wound was identified. In a separate incident, another nurse and a nurse aide performed wound care on a different resident without wearing gowns, despite EBP signage and PPE being available outside the resident's room. The nurse aide believed gowns were only necessary for incontinence care, and the nurse admitted he forgot to wear a gown due to being in a hurry, though he knew it was required. Both staff members had previously received education on EBP, but failed to comply with the policy during the observed wound care procedure.