Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Wounds
Penalty
Summary
Staff failed to consistently implement appropriate infection prevention and control measures related to Enhanced Barrier Precautions (EBP) for residents with wounds. One resident with a new left below-knee amputation and additional wounds was admitted to the facility, but EBP signage was not posted on the resident's door upon admission, despite an order for EBP being present. The signage was only put up the day after admission, resulting in staff not being alerted to the need for EBP and potentially not wearing required personal protective equipment (PPE) such as gowns and gloves during direct care activities. In another instance, a certified nursing assistant was observed providing incontinence care to a resident on EBP while wearing only a mask and gloves, but not a gown, despite adequate PPE supplies and EBP signage being present outside the resident's door. The CNA stated she sometimes wore a gown but did not consistently do so unless she saw an isolation sign. Interviews with nursing and infection control staff confirmed that gowns and gloves are required for high-contact care activities for residents on EBP, and that signage is essential to alert staff and visitors to the necessary precautions. Documentation and interviews further revealed that both residents had wounds requiring EBP, and that the facility's policy mandates the use of gowns and gloves during high-contact care activities for such residents. The lack of timely signage and inconsistent use of PPE by staff during direct care activities led to a failure in adhering to established infection control protocols for residents on EBP.