Failure to Follow Enhanced Barrier Precautions and Dressing Change Procedures During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBPs) and dressing change procedures, during wound care for one resident. The facility’s EBP policy requires gown and glove use for high-contact resident care activities, including dressing and wound care for residents with wounds, even when they are not known to be infected or colonized with MDROs. The dressing policy also outlines specific steps for hand hygiene, glove use, removal and disposal of soiled dressings, maintaining a clean field, and cleaning the bedside stand. These policies are intended to prevent the spread of MDROs and ensure clean technique during dressing changes. Resident 2 was admitted with multiple diagnoses including generalized muscle weakness, dysphagia (oral phase), and lumbar spine fusion, and had a care plan for a Stage II sacral pressure injury with interventions including skin care per facility guidelines and monitoring of the ulcer. During an observed sacral dressing change, an LPN entered the resident’s room and performed the dressing change without donning a gown, despite the EBP policy requiring gown and glove use for wound care. The LPN performed hand hygiene and glove changes but used a black marker taken from her pocket to label the dressing and did not clean the bedside table or the marker after use, contrary to the dressing policy’s requirement to clean the bedside stand. In a subsequent interview, the LPN acknowledged forgetting to wear PPE and confirmed that staff receive training on PPE requirements.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.