Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure staff followed its Enhanced Barrier Precautions (EBP) policy and failed to implement EBP for a resident with multiple open areas. The facility’s EBP policy, last reviewed 5/15/24, required the use of gowns and gloves during high-contact resident care activities, including wound care and dressing changes, for residents with wounds and/or indwelling medical devices, and directed that EBP signage be posted and PPE be available in the room. Review of the resident’s medical record showed diagnoses including hemiplegia following a left-sided stroke and high blood pressure. The resident’s care plan identified a pressure ulcer to the sacrum related to immobility and bowel and bladder episodes, with interventions to administer treatments as ordered and follow facility policies for treatment and prevention of skin breakdown, but there was no mention of EBP precautions. Further review of the electronic physician order sheet and January 2026 Treatment Administration Record showed no order for EBP precautions. During observation of wound care, two LPNs prepared to treat the resident’s large open wound to the buttocks. At the treatment cart outside the room, one LPN gathered wound care supplies, entered the room, and placed the items on a disposable pad on the bedside table. Both LPNs washed their hands; one LPN donned gloves and a gown from a shelf on the resident’s door and placed an extra gown on the bed, pointing to the other LPN, who donned gloves but did not put on the gown. Both staff assisted in rolling the resident to the left hip to expose the wound, during which the extra gown fell to the floor. One LPN removed the old dressing, cleansed the wound, changed gloves with hand hygiene in between, and applied the ordered treatment while the other LPN held the resident’s hips to maintain position, remaining gloved but ungowned throughout the high-contact wound care activity. After completing treatment, the gowned LPN removed the gown and gloves, performed hand hygiene, and removed trash from the room, while the ungowned LPN repositioned the resident and exited the room. In a subsequent interview, the DON and Administrator stated they would expect staff to follow the policy and for both nurses to wear appropriate PPE for EBP.
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