Failure to Adhere to Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During wound care for a resident on Enhanced Barrier Precautions (EBP), two Licensed Practical Nurses (LPNs) failed to wear gowns as required by the facility's infection control policy. The policy specifies that gowns and gloves must be used during high-contact care activities, such as wound care, for residents with wounds or medical devices like feeding tubes, urinary catheters, or tracheostomy tubes. Despite an EBP sign posted on the resident's door and the resident's care plan indicating the need for EBP due to impaired immunity and multiple invasive devices, the LPNs only performed hand hygiene and donned gloves, omitting the use of gowns. The resident involved had chronic respiratory failure, peripheral vascular disease, severe cognitive impairment, and was dependent on multiple medical devices, including an indwelling urinary catheter, feeding tube, and tracheostomy. The LPNs acknowledged after the incident that they should have worn gowns, attributing the oversight to the location of the gowns being on the other side of the hall. The Director of Nursing confirmed that EBP protocols require gown and glove use for hands-on care involving wounds or invasive devices.