Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with dementia and muscle weakness who had a forehead wound with sutures. Despite physician orders and care plans indicating the need for Enhanced Barrier Precautions (EBP) every shift, there was no signage or PPE cart present outside the resident's room on multiple observations. The resident's Treatment Administration Record (TAR) was signed as if EBP had been implemented, but staff interviews revealed confusion and lack of awareness regarding the resident's EBP status. The CNA was unaware of any isolation precautions for the resident, and the LVN did not recall signing the TAR or understand why EBP was ordered. The Director of Nursing (DON), acting as interim infection preventionist, also expressed uncertainty about the necessity of EBP for the resident and was unsure why the order was present or why staff had documented its implementation. The facility's infection control policy required EBP for residents with open wounds requiring a dressing, but the resident's wound was observed without a dressing. The lack of proper implementation and documentation of EBP, as well as staff confusion regarding infection control protocols, led to the deficiency.