Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wound
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic pressure ulcer on the right heel, which was discovered after removal of a hard cast and remained open, requiring ongoing dressing changes. During observation, no EBP measures were in place for this resident, despite facility guidelines requiring gowns and gloves for residents with chronic wounds. Interviews with the Infection Preventionist, the resident's case manager (LPN), and the Director of Nursing confirmed that EBP should have been in place for this resident, but staff were either unaware of the current precautions or acknowledged that EBP was not implemented as required. The deficiency was identified through observation, record review, and staff interviews, which collectively demonstrated a failure to follow established infection control guidelines for residents at increased risk for multi-drug-resistant organism transmission.