Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement infection control practices as outlined in its Enhanced Barrier Precautions (EBP) policy during wound care treatment for a resident with a Stage 3 pressure injury. During an observed wound care procedure, an RN and an LVN provided care to the resident without wearing the required isolation gowns, using only gloves. Additionally, there was no EBP signage posted near the resident's room doorway or bedside to alert staff and visitors of the necessary precautions. Both staff members acknowledged during the observation that EBP should have been followed, including the use of gowns and appropriate signage. The resident involved had moderate cognitive impairment and was on hospice care, with a sacrococcyx wound that had been reclassified as a Stage 3 pressure injury following debridement. The resident's care plan specifically required EBP during high-contact care activities, including wound care, and listed interventions such as ensuring the availability of PPE and posting EBP signage. The facility's Infection Preventionist, DON, and Quality Assurance Nurse all confirmed that EBP protocols were not followed during the observed incident.