F0880

D

Failure to Use Enhanced Barrier Precautions During Wound and Catheter Care

Riverton, Wyoming Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to implement its infection prevention and control program by not using enhanced barrier precautions during wound care for one resident. The resident had an open sacral wound documented by telephone order on 1/11/26 and an open wound on the right lower extremity documented in a progress note on 1/18/26. A hospital discharge summary dated 1/23/26 further showed the resident had been treated for a right lower extremity wound and cellulitis, had an open sacral wound, and had a newly placed Foley catheter. These conditions met the facility’s criteria for enhanced barrier precautions, including the presence of chronic wounds and an indwelling medical device.

During an observation of wound care on 2/5/26 at 9:22 AM, the DON and an LPN entered the resident’s room, performed hand hygiene, and donned gloves. The DON provided perineal and Foley catheter care due to incontinence of loose stool, then changed gloves and performed sacral wound care, including removal of the dressing, cleansing of the wound, and application of a new dressing, with hand hygiene and glove changes between steps. However, no gown or other additional personal protective equipment was used at any time during the care. In a subsequent interview, the DON stated that enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities, should be used for residents with wounds, catheters, and similar devices, and confirmed that this resident should have been on enhanced barrier precautions. Review of the facility’s Transmission-Based Precautions policy, last updated March 2025, showed that enhanced barrier precautions are required for residents with chronic wounds or indwelling medical devices.