Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of enhanced barrier precautions (EBP) during wound care for two residents. In one instance, a nurse (LVN B) provided wound care to a resident with a deep tissue injury on the right lateral ankle without wearing a gown, as required by EBP protocols. Although hand hygiene was performed and gloves were used, the omission of a gown during the procedure was acknowledged by the nurse, who stated that not wearing a gown could harbor bacteria. In another case, a different nurse (LVN C) performed wound care for a resident with pressure ulcers and moisture-associated skin damage on both heels. While a gown was worn, the nurse failed to follow proper infection control practices, including not performing hand hygiene at critical points, retrieving supplies from her scrub pockets under the gown with potentially contaminated hands, and not cleaning the wound cleanser bottle before returning it to the treatment cart. The nurse also removed her gown outside the room and did not perform hand hygiene before or after leaving the resident's room. Interviews with staff, including the Infection Preventionist, confirmed that the observed practices did not align with facility policy or CDC guidelines for EBP. The facility's infection control policy and CDC resources both require the use of gown and gloves for high-contact care activities and emphasize the importance of hand hygiene and proper handling of supplies. Requested documentation of infection control in-services and policies specific to EBP was not provided prior to the survey exit.