Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a stage three pressure injury. The resident, who had diagnoses including type two diabetes, Peripheral Vascular Disease (PVD), edema, and depression, was admitted on 04/21/23 and had physician orders for daily wound care and EBP due to the presence of wounds. The resident's door displayed a sign indicating the need for gown and glove use during high-contact care activities, such as wound care, in accordance with facility policy and physician orders. During an observation of wound care, the LPN performed hand hygiene and changed gloves between steps but did not don a gown at any point during the procedure, despite the EBP signage and policy requirements. The LPN confirmed in an interview that a gown was not worn and acknowledged the signage indicated its use was required for wound care. Facility policy reviewed stated that EBP involves targeted gown and glove use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms.