Failure to Follow Enhanced Barrier Precautions and Infection Control During Wound Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) and proper infection control protocols during wound care for a resident with a diabetic foot ulcer. Observation revealed that the resident had an EBP sign posted, indicating the need for hand hygiene and the use of gloves and gowns during high-contact care activities, including wound care. Despite these instructions, an LPN entered the resident's room, washed her hands, but did not set up a sterile field or bring all necessary dressing supplies before starting the dressing change. The resident's wound was actively bleeding, and the LPN applied pressure with soiled gauze, then wrapped the wound with the same soiled material before leaving the room to gather additional supplies. She did not sanitize her hands after removing her gloves and reused contaminated items, including scissors and bandages, during the dressing change. The soiled dressing supplies were left in the resident's garbage can in the room. The resident involved had a history of Type 2 Diabetes Mellitus with a foot ulcer, non-pressure chronic ulcer, adult failure to thrive, tobacco use, dependence on renal dialysis, and heart failure. The resident required moderate to partial assistance with activities of daily living and used a wheelchair for mobility. The provider's order specified a particular wound care protocol, which was not followed by the LPN, as she used betadine instead of saline and failed to maintain a clean and sterile environment during the dressing change. The LPN also failed to wear a gown and mask as required by EBP guidelines for residents with open wounds. Interviews with facility staff confirmed that the LPN was aware of the EBP requirements but did not adhere to them during the dressing change. The DON later performed the dressing change according to protocol, noting the previous errors, including the use of betadine and the lack of proper PPE and sterile technique. Facility policy and CDC guidelines reviewed in the report emphasized the importance of proper infection prevention measures, including the use of dedicated and clean supplies, hand hygiene, and appropriate PPE during wound care, all of which were not followed during the incident.