Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) protocol and CDC-based guidelines for use of personal protective equipment (PPE) during wound care. A cognitively intact resident with medical diagnoses including atrial fibrillation, chronic heart failure, a non-pressure chronic ulcer of the right foot, and peripheral vascular disease had a physician’s order for specific wound care to the right second toe. The resident’s care plan documented a requirement for EBP due to wounds, and a sign indicating EBP was posted on the resident’s door, with a PPE cart located outside the room. During observation, an LPN performed wound care on the resident’s right second toe, which had an open area with a moderate amount of yellow drainage and three yellow areas in the middle of the wound with a red and swollen periwound, but did not wear an isolation gown while providing this care. The resident reported having poor circulation in the right lower leg and stated that nurses did not usually wear a gown when providing wound care, further stating that staff should absolutely wear both gown and gloves when caring for the arterial wound on the right second toe. In a subsequent interview, the LPN acknowledged awareness that the resident was on EBP and on antibiotics for toe wounds requiring isolation precautions, and admitted she should have worn an isolation gown to help prevent the spread of bacteria. The facility’s Enhanced Barrier Precautions Protocol, revised April 8, 2024, specifies that PPE consisting of gloves and gown should be used during high-contact resident care activities such as wound care, which was not followed in this instance.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.