F0880

D

Failure to Use Enhanced Barrier Precautions During Wound Care

Waco, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The facility failed to maintain its infection prevention and control program when the infection prevention nurse (IP A) did not follow the facility’s Enhanced Barrier Precautions (EBP) policy during wound care for Resident #68. Resident #68 was an adult male with heart failure, hypertension, diabetes mellitus, and depression, with a BIMS score of 15 indicating intact cognition. His comprehensive care plan documented a chronic non-healing wound or indwelling medical device, placing him at increased risk for transmission of multidrug-resistant organisms (MDROs), and included interventions requiring staff to change personal protective equipment (PPE) before caring for other residents and to use PPE, including gown and gloves, during specific resident care activities such as dressing changes. The facility’s written EBP policy, dated March 2024, specified that gown and gloves are required for high-contact resident care activities, including wound care for any skin opening requiring a dressing.

On the observed date and time, IP A performed wound care to Resident #68’s right lower extremity wound, cleansing the wound, drying it, applying calcium alginate, and covering it with a dry dressing. During this procedure, IP A did not use enhanced barrier precautions, despite EBP signage being posted at the resident’s door indicating the need for such precautions. In a subsequent interview, IP A acknowledged that she should have used enhanced barrier precautions during the wound care, stated that it “slipped her mind,” and confirmed she had been educated on EBP and infection control, as well as that not using EBP could spread infection. The DON later confirmed that all nurses are expected to use enhanced barrier precautions when performing wound care and that nurse management is responsible for monitoring infection control and EBP use.