Failure to Follow Enhanced Barrier Precautions During Wound and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy for a resident with a coccyx pressure wound. The facility’s policy, revised on 05/19/2025, required staff to don both gloves and a gown for high-contact activities, including incontinence care and wound care, for high-risk residents such as those with wounds. Surveyor observations on two consecutive days showed that there was no EBP signage on the resident’s door and no PPE available outside the room, despite the resident reporting she had a sore on her bottom that was dressed daily. During a wound care observation, the Wound Care Nurse entered the room with wound care supplies in gloved hands, placed them on the bed sheet, and provided incontinence care and wound care without donning a gown at any point. Interviews revealed that the resident had not been placed on the Infection Preventionist’s EBP list because the Infection Preventionist was not aware the resident had a coccyx pressure wound. The Wound Care Nurse stated that the resident was not on the list of those requiring EBP and therefore no precautions had been implemented, although she thought it was odd the resident was not on precautions and did not question it. The Infection Preventionist stated she would have expected the Wound Care Nurse to wear a gown while providing incontinence and wound care, and the DON similarly stated he would have expected the resident to be on EBP and the Wound Care Nurse to use both gloves and a gown during care. These actions and omissions resulted in noncompliance with the facility’s EBP policy for infection prevention and control.
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