Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that staff followed enhanced barrier precautions (EBP) during wound care for a resident with significant medical needs. Specifically, during an observed wound care procedure, an LVN and a CNA donned gloves but did not wear gowns as required by the resident's care plan and facility policy. Both staff members acknowledged in interviews that they were aware of the EBP requirements, which included wearing both gloves and gowns for wound care, but stated they forgot to put on gowns during the procedure. The necessary personal protective equipment (PPE) was available, but not utilized as directed. The resident involved had a history of dementia and peripheral vascular disease, with a severely impaired cognitive status and ongoing pressure ulcer care. The care plan for this resident specifically indicated the need for EBP, including the use of gloves and gowns during high-contact care activities such as wound care. Facility policy also required EBP for residents with wounds, regardless of known infection status. Despite these documented requirements, staff did not adhere to the established precautions during the observed care event.