F0880

D

Failure to Use Required Enhanced Barrier Precautions During Wound Care

Avon, Indiana Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program by not using required enhanced barrier precautions (EBP) during wound care for a resident with a chronic pressure ulcer. During an observed dressing change to a mid-back wound, two LPNs wore masks and gloves but did not don gowns, despite a sign above the resident’s bed indicating EBP was required. One LPN assisted with positioning the resident on her side while the other completed the dressing change, both without gowns. When interviewed, the LPN performing the dressing change stated she believed the resident had been removed from EBP because the wound was small and did not explain why the EBP sign remained posted.

Record review showed that the resident’s electronic medical record banner indicated EBP was required, and wound documentation identified a pressure ulcer on the mid upper back first noted on 1/23/26. The care plan initiated on that date documented impaired skin integrity related to the pressure ulcer, with interventions including observation for signs and symptoms of infection. A separate care plan, last reviewed and revised on 1/28/26, stated the resident was at risk of transferring or becoming colonized with an MDRO and required EBP due to a chronic wound needing a dressing, with interventions to identify the need for EBP through signage and the medical record and to wear gown and gloves prior to high-contact care. A physician’s order directed daily dressing changes to the mid upper back wound, which was assessed on 3/9/26 as a stage 3 pressure ulcer with a granulation tissue bed. The facility’s EBP policy required gown and glove use for high-contact care activities, including wound care for chronic wounds such as pressure ulcers, and allowed discontinuation of EBP only when a wound placed on EBP had healed.