F0880

D

Failure to Implement Enhanced Barrier Precautions During Wound and Incontinence Care

Garland, Texas Survey Completed on 01-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) infection control program for residents with pressure ulcers. Resident #1, an older female with severe cognitive impairment (BIMS score of 0) and pressure ulcers on the sacral region and medial lateral foot, had a care plan requiring staff to wear gowns and gloves during high-contact care activities under EBP. A sign was posted on her door indicating EBP and the requirement for gown and gloves with all direct care. However, there was no PPE available outside her room at the time of observation.

On the observed date and time, RN A and CNA B provided incontinence care to Resident #1 while only wearing gloves and not donning gowns, despite the EBP signage and care plan requirements. Later, RN A performed wound care on Resident #1’s sacral and foot pressure ulcers, again wearing only gloves and not a gown. RN A followed hand hygiene and glove changes between steps but did not use a gown at any point during the wound care. In interviews, CNA B stated she knew she was supposed to wear PPE when an EBP sign was present and that staff should wear gowns and gloves when caring for residents with wounds, but she reported she did not recall seeing the sign and that there was no PPE cart at the door. RN A acknowledged she was aware of the requirement to wear a gown and gloves for Resident #1 under EBP, stated she forgot because she was anxious and there was no PPE bin by the door, and confirmed that failure to use EBP could lead to cross contamination.

Resident #2, an older female with moderate cognitive impairment (BIMS score of 10) and pressure ulcers on the sacral region and left ankle, also had a care plan requiring EBP with staff wearing gowns and gloves during high-contact care activities. During observation, LVN C performed wound care on Resident #2’s sacral and ankle pressure ulcers, including removal of old dressings with drainage, cleansing of the wounds, and application of collagen powder, calcium alginate, and dry dressings, while only wearing gloves and not a gown. In an interview, LVN C stated she forgot to wear PPE because she was nervous, noted that PPE had previously been placed in bins by residents’ doors but was not present that day, and acknowledged awareness of the requirement to wear a gown and gloves for Resident #2 under EBP and that failure to use EBP could result in cross contamination. The DON stated staff were required to wear gowns and gloves for direct contact with residents on EBP, such as turning, incontinence care, and wound care, and that EBP were in place to protect residents from exposure to infectious agents on providers’ clothing. Training records showed that RN A, CNA B, and LVN C had not attended the facility’s EBP training.