Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for three residents with pressure ulcers during a facility tour and subsequent record review. For each of these residents, staff did not use the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities involving chronic wounds. Specifically, one resident with a pressure ulcer on the right great toe was handled by staff without a gown, and there were no EBP signs or PPE set up in the room. Another resident with a sacrum wound was similarly handled by staff who did not don gowns before contact, and no EBP measures or signage were present. A third resident with a left heel wound also lacked EBP implementation, with no PPE or signage in place at the time of observation. The clinical records for all three residents showed relevant diagnoses, including type II diabetes mellitus, dementia, chronic kidney disease, and other comorbidities. Physician orders for wound care were present, but orders for Enhanced Barrier Precautions were not entered until after the surveyors' observations. Interviews with the Director and Assistant Director of Health Services confirmed that PPE should have been used and that EBP orders and signage were missing at the time of the survey. The facility's own policy required EBP for residents with chronic wounds, specifying the use of gloves and gowns during high-contact care, regardless of anticipated blood or body fluid exposure.