Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Injuries
Penalty
Summary
Nursing staff failed to implement and follow Enhanced Barrier Precautions (EBP) for a resident admitted with two Stage 2 pressure injuries, as required by the facility's infection control policy. The Infection Preventionist (IP) was not notified of the resident's wounds upon admission, and a physician's order for EBP was not obtained until after the issue was identified by a surveyor. During observations, there was no signage indicating precautions outside the resident's room, and no personal protective equipment (PPE) was available or used by staff providing direct care, except for gloves. Interviews with staff revealed a lack of awareness regarding the resident's need for EBP, with both CNAs and a nurse stating they were unaware of any required precautions or the presence of wounds that necessitated such measures. The Director of Nursing (DON) confirmed that residents with wounds should be placed on EBP immediately and reported to both the DON and IP, but this protocol was not followed in this case.