Failure to Follow Enhanced Barrier Precautions During Wound and Catheter Care
Penalty
Summary
Surveyors identified a failure to implement the facility’s Enhanced Barrier Precautions (EBP) policy during high-contact care for two residents with wounds and an indwelling device. One resident, admitted with post-polio syndrome, hemiplegia, lymphedema, muscle weakness, and dependence for personal care, had two stage 3 pressure injuries present on admission and a physician order for daily wound care to the right hip. During observed wound care, the wound care LPN repositioned the resident, removed the soiled dressing, cleansed, assessed, and redressed the right hip wound without donning an isolation gown, despite an EBP sign on the door specifying gown and gloves for wound care. The LPN acknowledged she did not wear a gown and confirmed she should have. The EBP supply cart located next to the resident’s door was observed with a thick layer of dust and grime and dried liquid spill marks. The resident later reported that staff never wore an isolation gown when providing care. Another resident, admitted with neuromuscular bladder dysfunction, muscle weakness, and need for assistance with personal care, had an indwelling Foley catheter, frequent bowel incontinence, and dependence for personal hygiene. The care plan documented EBP related to the indwelling Foley, with interventions including gown and gloves for high-contact care, and physician orders required Foley output measurement every shift. During observation of catheter care, a CNA emptied 300 milliliters of urine from the resident’s catheter drainage bag without donning an isolation gown and stated he did not need to wear one. The DON stated that staff providing catheter care, including emptying the drainage bag, or wound care should wear PPE including gloves and an isolation gown, and confirmed that the involved CNA and LPN worked throughout the facility and could expose all residents requiring care. The facility’s EBP policy specified that residents with wounds or indwelling medical devices require gown and glove use during high-contact care activities to reduce transmission of multidrug-resistant organisms.
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