Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers. According to the facility's policy and updated federal guidance, residents with chronic wounds, such as pressure ulcers, require EBP, which includes the use of gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Review of clinical records showed that a resident had unstageable pressure ulcers on the left heel and foot, with physician orders for daily wound care. However, there was no evidence that EBP was ordered or care planned for this resident until several days after the wounds were documented. Observations revealed that there was no signage or notification indicating EBP in the resident's room, nor was any personal protective equipment (PPE) available in or around the room during the survey. Staff interviews confirmed that the requirement for EBP was missed for this resident, despite the presence of pressure ulcers. The deficiency was cited under state regulations for failure to implement appropriate infection prevention and control measures.