Failure to Implement Enhanced Barrier Precautions for Resident with Stage 4 Wound
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident admitted with a stage 4 pressure wound to the sacrum. Upon admission, the resident had multiple diagnoses including type 2 diabetes mellitus, acute pain due to trauma, bilateral above-knee amputations, adult failure to thrive, stage III pressure ulcer of the sacral region, and peripheral vascular disease. Despite having an active order for wound treatment and dressing, there was no order or implementation of Enhanced Barrier Precautions (EBP) as required for residents with such wounds. The resident's baseline care plan was not completed, and the comprehensive care plan did not include EBP interventions. Observations revealed the absence of a PPE bin and signage outside the resident's room, and staff, including the ADON, provided wound care using gloves but not gowns. Interviews with staff indicated a lack of awareness and adherence to EBP protocols, despite documented training on infection control and EBP. The ADON, who performed wound care, acknowledged not using proper PPE and stated that the absence of signage contributed to this oversight. The infection control preventionist confirmed that EBP was necessary for the resident and that staff had been trained on the requirements. Facility policy required EBP for residents with wounds to reduce the transmission of multi-drug-resistant organisms, but this was not followed in the resident's care.