Failure to Follow Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and physician orders, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer. The resident, who was readmitted with muscle weakness and difficulty walking, had physician orders for EBP and wound care, including the use of gowns and gloves during high-contact care activities such as transfers and dressing changes. Despite clear signage and documented orders, staff did not consistently follow these protocols. During a wound dressing change, a registered nurse began the procedure without donning a gown, only putting it on after realizing the omission. The nurse also placed soiled dressing materials directly on the bedside table and failed to disinfect the area afterward. Additionally, the nurse exited the resident's room into the hallway while still wearing the gown, only returning to remove it after noticing the error. Further observations revealed that two nursing assistants entered the resident's room and performed a transfer using a Hoyer lift without wearing the required gown or gloves, despite the EBP signage and orders. Both nursing assistants acknowledged after the fact that they did not follow the EBP protocol. The staff educator confirmed that the expectation was for staff to adhere to infection control protocols and wear appropriate PPE as indicated by orders and signage. These actions and inactions directly led to the identified deficiency in the facility's infection prevention and control program.