Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow enhanced barrier precautions (EBP) during wound care for a resident. The resident, who had multiple complex medical diagnoses including cerebral infarction, BPH, Barrett's esophagus, GI hemorrhage, atrial fibrillation, dementia, and was dependent on a wheelchair, had a physician order for EBP due to wounds. The resident's cognition was severely impaired, as indicated by a BIMS score of 05. A CDC-published sign was posted at the resident's doorway, instructing all staff to clean their hands and wear gloves and a gown for high-contact care activities, including wound care. Despite these clear instructions, observation revealed that the RN entered the resident's room and began a dressing change without donning a gown. The RN confirmed during an interview that she had not put on a gown prior to starting the procedure. Review of the facility's policy on transmission-based precautions indicated that staff are to follow CDC recommendations and posted signage regarding the use of personal protective equipment (PPE). This failure to adhere to established infection prevention protocols resulted in non-compliance with the facility's infection prevention and control program.