Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed during incontinence and wound care for a resident with multiple wounds. The resident, who had chronic kidney disease, depression, and a history of transient ischemic attack, was always incontinent of bowel and bladder and required substantial assistance with activities of daily living. Despite being on EBP due to multiple wounds, there were no physician orders for EBP in the resident's medical record. During observed incontinence care, a CNA did not apply a gown as required by EBP protocols. Additionally, during a subsequent wound care procedure, an LPN also failed to wear a gown while treating a wound that had been contaminated by a bowel movement. Both staff members confirmed in interviews that they did not use gowns during these high-contact care activities. Facility policy and best practice guidelines reviewed indicated that gown and glove use is required for residents with chronic wounds during high-contact care, such as dressing, bathing, hygiene, and wound care, but these protocols were not followed in the observed instances.