Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident admitted with a Stage II pressure injury on the coccyx. The facility’s policy, effective 01/2023, required EBP for any resident with a wound, including chronic and surgical wounds, and specified that gowns and gloves must be worn for high-contact care activities such as wound care. The policy also required EBP signage to be posted outside the resident’s room and a precaution cart with gowns and gloves to be available, with precautions to remain in place for the duration of the resident’s stay or until the wound healed. Resident #2, admitted with diagnoses including schizoaffective disorder and type 2 diabetes mellitus, had a coccyx wound requiring daily dressing changes per physician order. On observation during a wound care dressing change, there was no EBP signage or precaution cart with gowns and gloves at the resident’s door, despite the resident meeting criteria for EBP under facility policy. The nurse performing the dressing change donned only a mask and gloves, did not wear a gown, and proceeded to remove the old dressing, cleanse the open, shallow coccyx wound with scant drainage and yellow tissue, apply Santyl, and place a new dressing. In interview, the nurse stated she did not think a gown was needed because the resident did not have MRSA and there was no EBP sign posted. The Infection Preventionist later confirmed that the resident should have been placed on EBP upon admission due to the presence of a wound and that the nurse should have worn a gown during wound care per facility policy.
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