Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that Enhanced Barrier Precautions (EBP) were implemented during wound care for a resident. Observation revealed that, although signage and personal protective equipment (PPE) were available outside the resident's room, the contracted wound care nurse only donned gloves and did not wear a gown while performing wound care. The facility's policy required both gown and glove use during high-contact resident care activities, such as wound care, for residents with wounds or indwelling medical devices. The resident involved was an older woman with a history of chronic embolism, thrombosis, an indwelling urinary catheter, a colostomy, multiple stage 2 pressure ulcers, unstageable pressure injuries, and a venous/arterial ulcer. Her care plan specifically indicated the need for EBP, including the use of gowns and gloves during wound care. Despite these documented requirements and the presence of appropriate signage and supplies, the contracted wound care nurse did not follow the established protocol during the observed wound care procedure.