Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices for one resident who had a stage four pressure injury on the sacrum. The resident's clinical record included a physician's order for daily wound care, which required cleansing the wound, patting it dry, and applying medihoney and foam. The facility's policy and a CDC sign on the resident's door both indicated that enhanced barrier precautions, including the use of gloves and a gown, were required during high-contact care activities such as wound care for residents with wounds. However, there was no physician's order for enhanced barrier precautions in the resident's record. During an observation of wound care, an LPN performed the procedure without wearing a gown, despite the posted instructions and facility policy requiring this personal protective equipment. The LPN acknowledged during an interview that the sign on the door instructed staff to wear a gown during wound care, but she did not comply. Facility administrative staff were made aware of the incident, and the facility's policy clearly outlined the need for enhanced barrier precautions for residents with wounds.