Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement proper infection prevention and control measures during wound care for a resident with a stage 4 pressure ulcer on the left hip. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of both gloves and a gown during high-contact resident care activities, such as wound care. During an observed dressing change, an LPN donned gloves but did not wear a gown as required by the facility's EBP policy. After completing the dressing change, the LPN removed her gloves, handled the trash bag, exited the resident's room, and disposed of the trash outside before performing hand hygiene upon reentry. The LPN acknowledged awareness of the EBP signage and policy, which specifically stated that a gown should be worn during wound care, but admitted to not wearing a gown during the procedure. The Nursing Home Administrator confirmed that staff are expected to follow the facility's infection control standards and EBP policy during wound care. The deficiency was identified through observation, interview, and record review, and involved a resident admitted with a stage 4 pressure ulcer and physician orders for regular wound care under enhanced barrier precautions.