Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not ensuring enhanced barrier precautions for a resident with chronic wounds. The resident in question had diabetic ulcers on the second and third toes of the left foot, which required daily dressing changes. Medical records confirmed the presence of these chronic wounds, and the resident's care plan included interventions for enhanced barrier precautions during various care activities. However, there was no physician's order for these precautions, and during multiple observations, there was no signage on the resident's door to indicate the need for enhanced barrier precautions. Interviews with facility staff revealed inconsistencies in the implementation of the precautions. The DON acknowledged that the care plan called for enhanced barrier precautions and that a caddy with personal protective equipment was present, but also confirmed that appropriate signage was missing. The Infection Preventionist stated that enhanced barrier precautions were not deemed necessary due to the small size of the wounds, based on information from the corporate office, but admitted there may have been a misunderstanding. No additional information was provided to clarify or correct the deficiency during the survey.