Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not utilizing Enhanced Barrier Precautions (EBP) for a resident requiring wound care. The resident had diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a stage 3 pressure ulcer, and required substantial assistance with toileting and bathing and partial assistance with ambulation. The MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. The resident’s care plan, dated 9/8/25, specified the need for EBP due to a wound, with goals to reduce the spread of infectious agents and minimize transmission of infection. Interventions directed staff to wear a gown and gloves for high-contact activities, keep PPE available near the room entrance, maintain signage on the door indicating required precautions and PPE, and practice good hand hygiene. On observation, the resident’s bedroom door lacked PPE signage and the room did not have PPE available for staff use. A RN entered the room to perform a daily dressing change and, contrary to the EBP requirements and facility policy, did not don a disposable gown while assembling supplies, elevating the resident’s foot, removing a soiled dressing with a dark substance, measuring the wound, performing the wound treatment, and re-dressing the wound. The RN acknowledged in interview that she did not wear a gown as required and attributed this to forgetting, noting the absence of a sign on the door and that the resident had recently changed rooms. The Assistant DON later stated that the resident had recently changed rooms and that staff must not have brought the sign and PPE to the new room. Review of the facility’s Transmission Based Precautions policy, updated 4/1/24, confirmed that EBP requires staff to don gowns and gloves prior to high-contact care activities such as wound care for any skin opening requiring a dressing.
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