Failure to Follow Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and wound care practices for one resident. The resident’s MDS dated 2/6/26 documented diagnoses of peripheral vascular disease and a venous ulcer, and the care plan initiated on 8/8/25 required EBP due to a PVD wound on the left lower leg, with EBP to be instituted during high-contact activities. Facility policy dated 3/25/24 stated that gloves and gown must be applied before performing high-contact resident care activities, including wound care. During an observation, a RN entered the resident’s room and placed wound treatment supplies directly on the resident’s bed, applied gloves without donning a gown, removed the resident’s sock and leg dressing, and cleansed scattered open wounds on the left lower leg. The RN then continued the procedure with the same gloves on while wrapping the leg with medicated dressing, gauze, and Coban, and only after completing the treatment removed gloves and performed hand hygiene. The RN then placed the wound cleanser and medicated dressing box back into the treatment cart with other residents’ supplies. A CMA interview confirmed that the EBP sign on the door meant staff should wear gown and gloves with all hands-on care, and the DON stated the expectation was to change gloves and perform hand hygiene when going from dirty to clean during wound treatment, to wear gown and gloves for the treatment, and to place supplies on a barrier.
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