Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with significant risk factors, including an indwelling catheter, severe cognitive impairment, and multiple unhealed pressure ulcers. According to the resident's care plan and physician orders, EBP was required due to the presence of open wounds and a urinary catheter, as well as a history of MRSA. During an observed wound care session, two LPNs provided treatment without donning gowns, although gloves were used. Their scrub tops came into contact with the resident's bed and covers during the procedure. PPE supplies were available outside the room, but the required gowns were not utilized. Interviews with the involved LPNs and facility leadership confirmed that staff were aware of the EBP requirements and had been trained to use both gloves and gowns during high-contact care activities such as wound care. One LPN incorrectly believed that EBP was no longer necessary since the resident had completed antibiotics and was not on contact isolation, while the Infection Preventionist and Director of Nursing clarified that EBP should have been maintained due to the ongoing presence of wounds and a catheter. Facility policy explicitly required the use of gloves and gowns for residents with wounds or indwelling devices during high-contact care, but this protocol was not followed during the observed incident.