Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control measures during wound care for a resident with a surgical wound and an active order for enhanced barrier precautions (EBPs). Specifically, during an observed wound care procedure, the Director of Nursing and an LPN wore only gloves, omitting the required gowns as specified by the resident's physician order and facility policy. The signage at the resident's door indicated the need for EBPs, including gloves and gowns, but this was not adhered to during the procedure. Additionally, the LPN was observed touching various potentially contaminated surfaces, such as tray tables, bed sheets, and the bed itself, with gloved hands and then using the same gloves to handle clean wound dressing materials without performing hand hygiene or changing gloves. This failure to maintain proper hand hygiene and use of personal protective equipment was confirmed by both the DON and the LPN during interviews, and it was inconsistent with the facility's written policy on isolation precautions and EBPs for residents with wounds.