Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the Director of Nursing (DON) not wearing a gown while performing wound care on a resident with a stage 4 pressure ulcer and a colostomy. The resident's care plan and physician orders specified the need for enhanced barrier precautions (EBP), including the use of personal protective equipment (PPE) such as gowns, gloves, and goggles during high-contact care activities like wound care. The DON confirmed during an interview that she did not wear a gown during the procedure, acknowledging this was a violation of the EBP protocol and infection control policy. Interviews with other nursing staff further confirmed that EBP should be implemented for residents with wounds, catheters, or ostomies, and that appropriate PPE is expected to be used during high-contact care activities. The facility's policy on enhanced barrier precautions, implemented in June, also required PPE during wound care. The failure to follow these established protocols was directly observed and verified through staff interviews and record review.