F0880

D

Failure to Use Required Enhanced Barrier Precautions During Wound Care

Thousand Oaks, California Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) for a resident with wounds. Physician orders dated 3/5/26 directed that the resident be on EBP due to foot and right buttocks wounds, and the facility’s policy on EBP, dated January 2025, required staff to implement EBP, including gown and glove use, for residents with wounds during high-contact care activities such as providing hygiene and changing briefs. The California Department of Public Health AFL 24-15 and CDC guidance also indicated that EBP, including targeted gown and glove use, should be implemented for residents with wounds regardless of MDRO colonization status. The resident’s Order Summary Report confirmed an active order for EBP due to the identified wounds.

During an observation on 3/4/26 at 3 p.m., a sign posted outside the resident’s room indicated that EBP were required. Despite this signage and the active orders, the Infection Preventionist (IP) and a CNA were observed inside the room changing the resident’s brief without wearing the required PPE gowns. In a subsequent interview, both the IP and the CNA acknowledged they should have been wearing gowns and were not. In a separate interview, the Administrator stated he was aware of the infection control issue because staff had informed him about it.