Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a pressure ulcer wound. During an observation of wound care, the Wound Treatment Nurse performed a dressing change for the resident without wearing the required protective gown, as stipulated by the facility's EBP policy. The nurse only wore gloves and did not don a gown at any point during the procedure, despite the resident having an open wound that required dressing. The nurse later acknowledged forgetting to put on the gown and indicated that the absence of visible signage in the resident's room contributed to this oversight. Further observations revealed that there was no visible personal protective equipment (PPE) such as gowns or gloves in the resident's room, nor was there appropriate signage posted to indicate the required PPE for high contact care activities. The only indicator present was a small magnetic banner on the door frame, which did not specify the PPE requirements. Interviews with staff, including the Wound Treatment Nurse and the DON, confirmed that signage and PPE should have been present and accessible, and that staff were expected to wear gowns and gloves for wound care under EBP. The lack of signage and accessible PPE contributed to the failure to adhere to infection control protocols during the observed care.