Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) during wound care for one resident with venous stasis ulcers. During an observed wound care procedure, a registered nurse and a wound technician did not wear gowns as required by facility policy, despite gowns being readily available in the room and signage indicating that EBP was necessary. The staff performed hand hygiene and wore gloves, but omitted the use of gowns. The physician present confirmed the wounds were venous stasis ulcers, which are considered chronic wounds under the facility's EBP policy. When questioned, the registered nurse stated that she believed gowns were only required if the wound was draining, not during all wound care. The unit manager clarified that staff had been in-serviced on EBP and that the policy requires the use of gowns for all wound care involving chronic wounds, regardless of drainage. The failure to follow the established EBP protocol was identified through observation, interview, and review of facility policy and records.