Failure to Implement Enhanced Barrier Precautions for Residents with Chronic Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with chronic wounds and stage 3 pressure injuries. For two of six residents observed, there were lapses in following facility policy and CDC guidance for EBP. One resident was readmitted with a hospital-acquired stage 3 pressure injury and was placed on EBP; however, there was no visible indication of EBP in place during surveyor observations, and the care plan documented discontinuation of EBP before the wound had fully healed. During wound care, the nurse did not follow EBP protocols, and staff interviews revealed uncertainty about the resident's EBP status and the criteria for discontinuing precautions. Another resident with a history of chronic wounds and a stage 3 pressure injury was not placed on EBP until after surveyor observation of drainage from leg wounds. The care plan lacked documentation of EBP implementation following the resident's hospital readmission with a stage 3 pressure injury. Staff interviews indicated confusion about when EBP should be initiated and who is responsible for making that decision. There was also a delay in placing the resident on EBP after the onset of wound drainage, and staff were unclear about the chronicity and management of the wounds. Throughout the investigation, surveyors noted inconsistent application of EBP, lack of proper signage, and inadequate communication among staff regarding infection control measures. Staff members, including the DON and ADON, provided conflicting information about the criteria for EBP and the status of residents requiring precautions. Observations included therapy and nursing staff providing care without appropriate personal protective equipment, despite care plans indicating EBP was still in effect. These actions and inactions resulted in the facility not maintaining a safe and sanitary environment to prevent the transmission of communicable diseases and infections.