Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement and use enhanced barrier precautions (EBP) for a resident with an open pressure ulcer, as required by both facility policy and federal guidelines. The resident, who had multiple diagnoses including diabetes, chronic kidney disease, and peripheral vascular disease, was admitted with pressure ulcers and later developed an unstageable wound with drainage and slough. Despite these conditions, there was no physician order for EBP, no EBP signage in the resident's room, and the care plan did not address EBP. During wound care, the RN/Wound Nurse performed hand hygiene and wore gloves but did not don a gown, which is required for high-contact care activities under EBP protocols. The infection control preventionist was present during the procedure but did not intervene or provide hands-on care. Interviews with nursing staff and the Director of Nursing confirmed that EBP should have been implemented, including the use of a gown during wound care. The oversight was attributed to the initial status of the wound, which was not open, but staff acknowledged that EBP should have been initiated once the wound opened. Review of facility policy and the CMS memorandum confirmed that EBP is indicated for residents with wounds, regardless of known infection or colonization status. The failure to implement EBP was observed in one resident out of two reviewed for EBP, despite the facility identifying multiple residents requiring such precautions.