Failure to Implement Enhanced Barrier Precautions for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the implementation of enhanced barrier precautions for a resident with a pressure ulcer. Facility policy titled "IC-Enhanced Barrier Precautions," revised April 1, 2024, stated that enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained, and when contact precautions do not otherwise apply. Clinical record review for Resident 5 showed diagnoses including a stage 3 pressure ulcer of the sacral region and diabetes. A wound team consult dated March 2, 2026, documented that the resident had a stage 3 sacral pressure ulcer. On multiple observations of the resident’s room door, surveyors did not see any signage indicating that the resident was on enhanced barrier precautions or that PPE was required when providing care. During observation of the resident’s stage 3 pressure ulcer treatment, the ulcer was noted to be healing but still presented as an open area on the sacrum. Review of the physician’s orders did not show any order for enhanced barrier precautions for this resident, and review of the care plan did not reveal any care plan addressing the need for enhanced barrier precautions. In an interview, the DON stated she believed the resident’s pressure ulcer had closed and that enhanced barrier precautions were no longer needed. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
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