Failure to Implement Enhanced Barrier Precautions During Wound Care
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 facility policy and current CDC guidance, residents with chronic wounds require the use of gloves and gowns during high-contact care activities, such as wound care, and appropriate signage must be posted to alert staff of these requirements. However, during an observation of wound care for a resident with pressure ulcers, there was no EBP signage posted outside the resident's door, and the LPN performing the wound care did not don a gown as required by EBP protocols. Interviews with the RN Supervisor and the Assistant Director of Nursing confirmed that the resident should have had EBP signage and that the LPN should have worn a gown during wound care. The resident was cognitively intact and had a physician's order for EBP isolation due to pressure ulcers. The failure to implement these infection control measures was identified through review of clinical records, facility policy, and direct observation.