Failure to Follow Enhanced Barrier Precautions and Maintain Ostomy Care Orders
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an unstageable pressure ulcer. During incontinence and wound care, two Qualified Medication Aides and a Wound Nurse did not don EBP supplies as required by physician orders and facility policy. The resident's clinical record also lacked a care plan related to EBP, despite an active order for EBP until the wound was healed. The Assistant Director of Nursing confirmed that EBP should have been used during these care activities. Additionally, for a resident with a colostomy, there were no physician orders in place for the care of the ostomy, as confirmed by review of the clinical record, Treatment Administration Record, and Electronic Medication Administration Record. The facility's policy requires licensed nurses to provide ostomy care under the orders of the attending physician, specifying the type of ostomy, frequency of pouch change, and type of equipment. This omission was acknowledged by nursing staff and was not in accordance with facility policy.