Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow infection control protocols during a wound dressing change for a resident with multiple medical conditions, including diabetes and a right leg amputation. The resident had an active order for Enhanced Barrier Precautions (EBP) due to a right elbow wound, which required the use of gown and gloves during high-contact care. During observation, the LPN removed the old dressing, cleansed the wound, and applied new dressings as ordered, but did not don the required personal protective equipment (PPE) such as a gown while providing care. The LPN was unaware that the resident was under EBP, mistakenly believing that the precautions applied to the roommate instead. The signage on the door did not specify which resident in the double occupancy room was under EBP, contributing to the confusion. The Director of Nursing confirmed that the signage failed to identify the correct resident requiring EBP. Facility policy required EBP for residents with chronic wounds needing dressings, but this protocol was not followed during the observed wound care event.