Failure to Timely Implement Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who was admitted with multiple wounds and a history of MRSA. Upon admission, the resident had a right femur fracture, several pressure ulcers, a deep tissue injury, and a recent surgical history, including a hip replacement and right lung lobectomy. Despite these risk factors, Enhanced Barrier Precautions (EBP) were not implemented until six days after admission, as evidenced by the Medication Administration Record and order summary. Staff interviews revealed inconsistent understanding and implementation of EBP, with several nursing assistants and licensed nurses relying on posted signs or direct communication to determine when EBP was required, rather than a systematic approach at admission. The Director of Nursing acknowledged that EBP should have been initiated upon admission for residents with open wounds, and could not explain the delay in this case. The facility's infection control policy required transmission-based precautions when standard precautions were insufficient, but this protocol was not followed for the resident in question. The deficiency was identified through record review and staff interviews, which confirmed that the lack of timely EBP implementation placed the resident and others at risk for cross-contamination and infection spread.