Failure to Implement Enhanced Barrier Precautions for Resident With Chronic Wound and Hardware
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) infection control practices for a resident with a chronic wound and indwelling hardware. The resident had diagnoses including osteomyelitis of the left ankle and foot and had moderate cognitive impairment. A wound assessment dated 10/24/25 documented old hardware/screw coming through the skin. During an observation of wound care on 2/19/26, an LPN gathered supplies and entered the resident’s room, where there were no indications that EBP should be followed. The LPN performed wound care to the left ankle, removing a light brown crusted covering and exposing a silver metal screw head protruding just above the skin surface, while wearing gloves but not a gown. In an interview immediately after the observation, the LPN stated there were no signs indicating that nursing staff should follow EBP and that they would check records to clarify whether EBP was required for this wound care. Review of the clinical record confirmed the presence of old hardware/screw coming through the skin, and the facility lacked an order to follow EBP for this resident. The DON indicated that the wound was from an old surgery and that, because the skin was not open, the interdisciplinary team did not feel the wound met EBP criteria. However, the facility’s current EBP policy, revised 3/2025, stated that EBP are used for residents with chronic wounds and/or indwelling medical devices regardless of MDRO status, as well as for residents with infection or colonization with a CDC-targeted MDRO when contact precautions do not apply.
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