Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple risk factors. The resident in question was an older male with multiple sclerosis, two stage 4 pressure ulcers, and an indwelling catheter, all of which required EBP according to facility policy and posted signage. Despite clear care plan interventions and posted instructions at the resident's room, staff did not adhere to required infection control measures. During wound care, three staff members, including the wound care nurse, MDSC, and DON, entered the resident's room and performed high-contact care activities without donning gowns as required by EBP protocols. Their uniforms came into direct contact with the resident's bedding and gown, and at times, soiled gloves were used to touch room surfaces. The wound care nurse and other staff acknowledged in interviews that they should have worn gowns to prevent cross-contamination, and that failure to do so could result in the spread of infection. Record reviews confirmed that the facility's infection control and EBP policies required the use of gowns and gloves during high-contact care for residents with wounds or indwelling devices. Despite these policies and staff training, the required precautions were not followed during the observed wound care, as staff failed to don gowns and allowed their uniforms to become contaminated during the procedure.