Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for one resident with a pressure injury, as required by facility policy and infection prevention protocols. The policy specified that EBP, including the use of gown and gloves, must be used during high-contact care activities such as wound care for residents with certain types of wounds. The resident in question had a diagnosis of high blood pressure, heart failure, and atrial fibrillation, and was documented to have an unstageable pressure injury on the sacrum that required daily dressing changes with Dakins solution and gauze. On direct observation, there was no evidence that EBP was in place for this resident, despite the presence of a pressure ulcer. During a wound care procedure, an LPN failed to don a gown as required by EBP guidelines. The Director of Nursing confirmed that EBP had not been implemented for this resident. These findings were based on a review of facility policies, clinical records, direct observation, and staff interviews.