Failure to Implement Enhanced Barrier Precautions for Resident with Multiple Wounds
Penalty
Summary
Facility staff failed to implement and adhere to their infection prevention and control program by not following enhanced barrier precautions (EBP) for a resident with multiple open wounds and a Foley catheter. During observations, certified nursing assistants entered the resident's room without donning any personal protective equipment (PPE), and there was no signage on the door to indicate any type of precautions. The resident, who had a stage IV pressure ulcer to the sacrum and three stage III pressure ulcers to the right foot, was not identified as requiring EBP in the care plan, and no physician orders for EBP were present. Interviews with staff revealed a lack of awareness and inconsistent understanding of when EBP should be implemented. Certified nursing assistants stated that no residents were currently on precautions and that signage would be present if precautions were needed. One LPN reported only using gloves for wound care and was unfamiliar with the need for EBP in the absence of a known multidrug-resistant organism (MDRO). The director of nursing, who had recently started at the facility, acknowledged that the resident should have been on EBP and noted gaps in staff education and infection control processes. Review of facility policy and CDC guidance confirmed that residents with wounds or indwelling medical devices should be placed on EBP, regardless of MDRO status. The facility's failure to implement EBP for the resident with multiple wounds and a Foley catheter was not in accordance with national standards or the facility's own policy, as evidenced by the lack of PPE use, absence of signage, and omission from the care plan.