Failure to Maintain Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain enhanced barrier precautions (EBPs) during wound care for one resident who was identified as requiring these precautions. Observation revealed that two nurses provided wound care to a resident with multiple complex medical conditions, including an above-the-knee amputation, unstageable pressure ulcers, and a history of Methicillin susceptible Staphylococcus aureus infection. Despite a sign posted outside the resident's door indicating the need for gown and gloves during high contact care, both nurses did not don gowns while performing wound care. Their uniform tops came into direct contact with the resident during repositioning and treatment. Interviews with the involved nurses confirmed their awareness that the resident required EBPs during wound care and acknowledged that they had not worn gowns as required. Review of the facility's policy, revised in March 2024, specified that EBPs, including the use of gowns and gloves, are necessary during high contact care activities such as wound care to reduce the transmission of multidrug-resistant organisms. The failure to follow these precautions was identified through observation, record review, staff interviews, and policy review.