Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During the annual survey, it was observed that the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a history of orthopedic surgery and a surgical wound infection. The resident had been admitted with severe sepsis secondary to a right ankle wound infection, had undergone multiple surgeries, and was receiving ongoing wound care and antibiotics. Facility policy and CMS guidance both required the use of gown and gloves for high-contact care activities, such as wound care for residents with unhealed surgical wounds. Despite signage indicating EBP requirements, a registered nurse performed a dressing change using only gloves and did not wear a gown. The nurse confirmed after the procedure that she did not wear a gown and stated that the resident was not on EBP precautions, despite the presence of unhealed surgical wounds and posted signage. Review of facility policy and the CMS QSO-24-08-NH memo confirmed that EBP, including gown and glove use, was indicated for residents with chronic or unhealed surgical wounds. This incident was identified as a deficiency and was also noted as evidence of continued non-compliance from a previous survey.