Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures during wound care for one resident on Enhanced Barrier Precautions (EBP). The resident was admitted with multiple diagnoses including hemiplegia, hemiparesis, type II diabetes, dysphagia, cerebral infarction (stroke), depression, anxiety, right knee contracture, hypertension, and heart failure. A quarterly MDS documented that the resident was cognitively impaired, dependent on staff for hygiene and transfers, and had a stage II pressure ulcer and moisture associated skin damage. The care plan indicated the resident required EBP due to a multidrug resistant organism (MDRO) infection in a right foot wound, and physician orders directed cleansing the right fifth toe with normal saline, patting dry, applying calcium alginate, and covering with a foam dressing. During an observation of wound care, an LPN gathered supplies and entered the resident’s room, which had signage indicating EBP and the requirement for staff to wear gloves and a gown when providing wound care to any skin opening requiring a dressing. The LPN did not don a gown, washed her hands, put on gloves, and removed the old dressing from the right fifth toe. Using the same gloves that had been used to remove the soiled dressing, she then cleansed the wound and applied calcium alginate before changing gloves to apply the foam dressing. In a subsequent interview, the LPN confirmed she did not change gloves after removing the dressing and before cleansing the wound, and acknowledged that the resident required EBP and that she was required to wear gloves and a gown while providing wound care. Review of the facility’s wound care policy showed it required handwashing, glove use to remove the dressing, handwashing again, and then new gloves to complete the dressing change. This deficiency was investigated under Complaint Numbers 2703441 and 2642470.
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