Failure to Implement Enhanced Barrier Precautions for Resident With Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies for enhanced barrier precautions for a resident with a sacral wound. The facility’s policy, last revised in December 2025, required enhanced barrier precautions to prevent transmission of multidrug-resistant organisms. On two separate observations of the resident’s room and the hallway outside, there was no enhanced barrier precaution signage on the door and no PPE available outside the room, despite the resident having a sacral wound. During an observation of incontinence care, the nurse aide initially entered the room and began care wearing only gloves, without a gown, and turned the resident before the surveyor intervened upon noticing the sacral wound and foam dressing. After being stopped, the nurse aide removed her gloves, performed hand hygiene, exited the room, and then reentered wearing a surgical mask and gown and donned gloves before continuing care. In an interview, the nurse aide stated she would have donned PPE before providing care if enhanced barrier precaution signage had been posted, explaining she had been trained to put on PPE when a sign was present. The ADON confirmed that the resident had a wound, should have had an enhanced barrier precautions sign on the door, and that the nurse aide should have donned PPE prior to providing care. The Administrator also stated that her expectation was that residents requiring enhanced barrier precautions would have signage and accessible PPE prior to care.
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