Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to consistently follow infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene during wound care for two residents receiving wound treatment. For one resident with a stage 4 pressure ulcer and significant cognitive impairment, a nurse performed a dressing change while following some EBP protocols, such as donning a gown and performing hand hygiene. However, the nurse did not use a barrier for wound care supplies, placed a multi-resident wound cleanser bottle directly on the bedside drawer, and returned the bottle to the treatment cart without sanitizing it. For another resident with multiple wounds, severe cognitive impairment, and a Foley catheter, staff did not wear gowns during high-contact wound care activities despite EBP signage on the door. The LPN removed soiled dressings and applied new ones without changing gloves or performing hand hygiene between steps. The LPN also used a personal marker while wearing contaminated gloves and returned it to her pocket without cleaning it. During the dressing change on a different wound, gloves were changed but hand hygiene was not performed after glove removal. Interviews with staff confirmed awareness of EBP protocols and the need for gowns and hand hygiene during high-contact care, but acknowledged lapses in practice. The Infection Preventionist and Director of Nursing both stated that staff were educated on these protocols and that expectations included consistent adherence to infection control practices, including hand hygiene and use of PPE for residents with wounds or indwelling devices.