Failure to Implement Enhanced Barrier Precautions During Wound and High-Contact Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care and high-contact resident care activities for five residents observed for wound care. Surveyors observed multiple instances where staff did not don gowns and, in some cases, failed to perform hand hygiene between glove changes or after removing gloves. For example, a registered nurse performed wound treatments on a resident with multiple wounds and an EBP sign posted, but did not wear a gown, changed gloves without hand hygiene, and left the room with contaminated gloves to retrieve supplies. The nurse also handled supplies and equipment with soiled gloves and did not clean the treatment cart after use. Another resident on EBP for a skin tear and on isolation for a respiratory virus received wound care from staff who wore gloves and masks but did not wear gowns as required. Staff entered the room and performed wound care without donning gowns, and hand hygiene was inconsistently performed between residents and glove changes. In a separate case, a resident with multiple wounds did not have an EBP sign posted, and the nurse did not wear a gown or perform hand hygiene after care. The nurse admitted to forgetting to wear a gown and not always using hand sanitizer between glove changes. Additional observations included a nurse using uncleaned scissors on a resident's wounds and not wearing a gown, as well as certified nursing assistants performing incontinent care on a resident with an EBP sign posted but not wearing gowns or understanding the meaning of EBP. Facility policies required the use of gowns and gloves for high-contact care activities for residents meeting EBP criteria, but these protocols were not consistently followed, as evidenced by direct observation, staff interviews, and record review.