F0880

E

Failure to Implement Enhanced Barrier Precautions for Residents With Wounds

Warrensburg, Missouri Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy and CDC-recommended practices for residents with wounds and infection risks. The facility’s EBP policy required gown and glove use for residents with certain infections, wounds, and/or indwelling medical devices during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, toileting assistance, device care, and wound care. CDC guidance similarly called for hand hygiene for everyone entering and leaving the room and gown and glove use for high-contact care activities for residents who meet EBP criteria. Surveyors found that EBP was not being used for any of the sampled residents with wounds, and staff and leadership reported they had not discussed or implemented EBP in the facility.

One resident had diabetes, a skin infection, and a non-pressure chronic ulcer of the left foot, with a documented diabetic foot ulcer and wound infection. The care plan identified skin impairment related to diabetes and a chronic wound, and the treatment record showed ongoing wound care to the left great toe, including cleansing and application of Iodoflex and dressings. A wound care provider note documented a chronic left great toe wound, prior IV antibiotics for chronic osteomyelitis, and a long-standing diabetic ulcer with specific measurements and wound characteristics including serosanguineous exudate, slough, granulation tissue, and necrotic tissue. During observed wound care by the DON, there were no EBP signs or PPE outside the room, the DON wore gloves and performed hand hygiene but did not wear a gown, and the DON stated they had not talked about or used EBP at the facility.

Another resident with diabetes had documented abrasions to both knees and a vascular wound to the left lower leg, with physician orders for daily cleansing and application of calcium alginate and foam dressings to the left lower extremity wound. Observation showed dressings on both shins and no EBP signage or PPE outside the room. The DON again stated that EBP had not been discussed or used. A third resident had an open wound on the left foot, osteomyelitis, and a chronic foot wound, with care plan entries for risk of infection and actual skin integrity impairment related to a chronic foot wound. Treatment orders included cleansing and dressing of plantar areas on both feet and application of calcium alginate to an open wound on the right foot, with skin observation documenting a callous on the left foot and a chronic wound on the right plantar surface. During observation, there were no EBP signs or PPE outside the room, the DON reported the resident had wounds on the bottom of both feet, and confirmed that EBP had not been discussed or used.

Staff interviews further demonstrated the lack of implementation of EBP and incomplete use of PPE during wound care. A Certified Medication Technician reported hardly ever seeing nurses use gloves during wound treatments, seeing nurses perform wound treatments without gowns, and not knowing where gowns were located. The DON stated they had not talked about EBP and had not used EBP for any residents. The Administrator reported that EBP had not been done and did not believe the facility had an EBP policy, despite the written policy reviewed by surveyors. The Infection Preventionist stated they had never heard of EBP prior to the survey date. An LPN reported that administration had not instructed staff to use EBP, that they only wore gloves during wound treatments, and that they did not wear gowns when performing wound care. These observations and interviews show that the facility did not implement EBP for residents with wounds as required by its policy and CDC guidance.