Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as ordered by the physician during wound care for a resident with multiple comorbidities, including congestive heart failure, chronic kidney disease, diabetes mellitus, and morbid obesity. The resident required assistance with activities of daily living and had wounds that necessitated EBP during high-contact care activities. The care plan and physician orders specified the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care such as wound care. During an observed wound care procedure, two nurses provided care to the resident's sacrum/right buttocks without wearing gowns, contrary to both the physician's orders and the facility's EBP policy. The nurses confirmed in interviews that a gown should have been worn during the procedure. Review of the facility's policy and CDC guidance further supported the requirement for gown and glove use during high-contact care for residents with wounds. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for wounds.