Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) for residents with wounds, as required for infection prevention and control. Observations and record reviews revealed that multiple residents with chronic or open wounds did not have EBP signage or personal protective equipment (PPE) such as gowns and gloves available outside their rooms. In several cases, care plans and physician orders did not include EBP, and staff interviews confirmed the absence of these precautions. One resident with severe cognitive impairment and an unstageable pressure ulcer did not have EBP signage or PPE outside her room, and staff confirmed she was not under EBP. Another resident with a stage three pressure ulcer to the right heel also lacked a care plan for EBP, and there were no EBP orders or PPE available outside the room. A third resident with a stage four pressure ulcer of the sacral region similarly had no EBP care plan or orders, and staff confirmed the absence of EBP measures. Additionally, a resident with a left hip wound and a wound vacuum in place did not have EBP signage or PPE outside the room during multiple observations. Staff interviews indicated that PPE was stored at the nursing station rather than being immediately accessible near the resident's room. The Director of Nursing confirmed that EBP is necessary for residents with chronic wounds, but the required precautions were not in place for these residents.